BRIEF REPORT

Past Utilization of Geriatric
Psychiatry Outpatient Services
by a Cohort of Patients
With Major Depression
Peter M. Aupperle, M.D., M.P.H.
Rebecca Lifchus, B.A.
Andrew C. Coyne, Ph.D.
The authors examined past utilization of outpatient psychiatric services by elderly depressed patients. A chart review identified 49 patients (mean age‫ )4.96ס‬who had
ceased active treatment, of whom 28 were successfully contacted. Reasons for discontinuation were 1) patient perception that care was no longer needed (51.5%); 2) existence
of barriers to care (33.3%); and 3) perception that treatment was ineffective (15.2%). Findings included 1) a higher
number of visits by patients referred from a non-healthcare
source and by married patients; 2) lower Beck Depression
Inventory scores among those who reported that they did
not need additional treatment; and 3) a greater willingness
to re-engage in treatment by those patients with a higher
number of visits during their previous treatment. Patient
characteristics and source of referral were associated with
both past service utilization and likelihood of future usage;
however, many individuals do not access treatment because
of both practical and attitudinal barriers to care. (Am J Geriatr Psychiatry 1998; 6:335–339)

A

lthough previous studies have demonstrated that elderly individuals experience the same spectrum of psychiatric
disorders as their younger counterparts,1
only limited information is available regard-

ing how elderly patients utilize mental
health services. Also, the literature that
does exist points to an underutilization of
mental health services by older adults. For
example, elderly patients use outpatient

Received September 3, 1997; accepted February 9, 1998. From the Division of Geriatric Psychiatry, Department
of Psychiatry, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway, New Jersey. Address correspondence to Dr. Aupperle, COPSA Institute, UMDNJ–UBHC, 667 Hoes Lane,
P.O. Box 1392, Piscataway, NJ 08855-1392.
Copyright ᭧ 1998 American Association for Geriatric Psychiatry
THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

335

Psychiatry Outpatients and Depression

psychiatric services at a rate that is only
half that expected on the basis of their proportion of the population.2 One reason for
this finding is that elderly individuals are
more likely to seek help for their emotional
and psychiatric problems from their general physicians.3 Furthermore, older adults
are nearly five times more likely than
younger adults to present in an emergency
room than in a community mental health
center for mental health care4 because
acute symptoms often precipitate a comprehensive psychiatric and medical evaluation. Other explanations for this decreased utilization include lack of a social
support network,5 resource-related barriers (e.g., lack of transportation and affordability),5 insufficient engagement in treatment,6 and perceived lack of treatment
efficacy.7
In contrast to studies of underutilization, several factors have been identified
by Lebowitz and associates8–10 that increase utilization of geriatric outpatient
mental health services. These include the
presence of a specialized geriatric program, affiliations with local Area Agencies
on Aging, and staff trained in geriatric mental health care delivery. Community mental
health centers that have incorporated
these factors are more likely to overcome
barriers to care (e.g., the stigma of mental
health care in an elderly cohort, the lack
of access to such care, and the lack of psychiatric care tailored to a geriatric population).11,12
In light of the limited existing research, the present study was designed to
investigate longitudinal patterns of utilization of geriatric psychiatry outpatient services. We studied a cohort of elderly patients who had previously received
outpatient psychiatric treatment for an episode of major depressive disorder
(MDD).13 Data were collected about 1) referral to treatment; 2) number of visits during active treatment; 3) perception of (reasons for) the termination of treatment; and
336

4) attitude toward re-engaging in treatment.

METHODS
The sample studied consisted of patients
of the Department of Geriatric Services,
University of Medicine and Dentistry of
New Jersey (UMDNJ)—University Behavioral HealthCare (UBHC), a universitybased, ambulatory-outpatient psychiatric
clinic that incorporates many of the “barrier breaking” factors (e.g., a community
outreach program and specialized staff)
identified by Lebowitz and associates.8–10
A retrospective chart review identified all
patients with a sole clinical diagnosis of
MDD who had ceased active treatment
over the past 3 years. Patients were not included if they had any additional Axis I diagnoses, such as substance abuse or dementia. This particular cohort was selected
for study because elderly patients with
MDD are often encouraged to continue
treatment indefinitely, given the need for
either maintenance treatment or close
monitoring for relapse.
Of the 49 patients identified, 28
(57.1%) were successfully contacted and
provided written consent for participation.
Among those not contacted, five patients
were deceased, seven could not be
reached because they were in nursing
homes, six refused to participate in the
study, and three could not be reached. The
patients not contacted were compared as
a group with those who were included in
the study. Chi-square analyses indicated
that the two groups did not differ in terms
of sex, race, marital status, and living arrangements (all Ps Ͼ0.05). Also, analyses
of variance indicated no group differences
in terms of age or years of education completed (Ps Ͼ0.05).
Demographic data (e.g., age, race, gender, marital status, living arrangement, education) were collected via standardized
VOLUME 6 • NUMBER 4 • FALL 1998

Aupperle et al.

chart reviews. Data regarding associated
major life stressors, the number of visits
during the course of treatment, referral
source, and all five DSM-IV axes were also
recorded.
A structured telephone survey was devised and prospectively administered to
participants. The survey was used to determine the patients’ perceptions of why
active treatment ceased (e.g., they no
longer believed that they needed treatment; they experienced barriers to care;
they felt treatment was ineffective). Current mood and present utilization of health
services were also assessed—by asking
questions about whether the patient might
be using care outside of the UBHC or utilizing no care at all—and asking whether
they would seek mental health care in the
future if symptoms recurred.
Level of depression was assessed with
the Beck Depression Inventory (BDI)14 administered by telephone, a technique that
has been used in previous studies.15,16
Those patients who met the criteria for
moderate or major depression (BDI
scoreϾ16) and who reported limited use
of medical or psychiatric health care (in
settings other than UBHC) for their depression were encouraged to re-engage
with psychiatric outpatient services at
UBHC.
Nonparametric and correlational analyses of the data were performed with the
SAS Language for Personal Computers. The
protocol was approved by the UMDNJ Institutional Review Board.

RESULTS
Among the 28 patients interviewed, the
mean age was 69.4‫ 8.8ע‬years; 67.9% were
women; 85.7% were white, 10.7% black,
and 3.6% were Hispanic. With respect to
marital status, 42.9% were married, and
57.1% were unmarried (i.e., widowed, divorced, separated, or single). In terms of
THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

living arrangement, 46.4% were living
alone, and 53.6% had other living situations (e.g., with spouse, family, assisted living). Results indicated that the mean number of outpatient mental health visits
among married individuals was 26.3, and
the mean number of outpatient visits
among unmarried individuals was 8.3 (Wilcoxon rank-sum statistic S‫ ;152ס‬PϽ0.05).
On the other hand, age, gender, race, living
arrangement, and major life stressors were
not associated with the number of outpatient mental health sessions used (all
PsϾ0.05).
One variable that was found to differentiate patient populations was referral
source. Analyses indicated that a patient referred to UBHC from a non-healthcare
source (e.g., church, senior center, friend,
family, self) utilized a greater number of
outpatient services (mean number of visits‫ )0.11ע6.41ס‬than a patient who was
referred to UBHC via a healthcare source
(e.g., outpatient or inpatient clinic; mean
number of visits‫ ;1.7ע2.5ס‬Wilcoxon
rank-sum statistic, S‫ ;00.981ס‬PϽ0.05).
Reasons for termination of treatment
were also examined. The 28 patients surveyed provided a total of 33 reasons for
their perception of why treatment was discontinued (mean number of responses per
patient‫ .)2.1ס‬These included patient perception that care was no longer needed
(51.5%), the existence of resource-related
barriers to care (33.3%), and patient perception of lack of treatment efficacy
(15.2%).
Data regarding patients’ self-reports of
current mood were also examined. Patients who reported they were not depressed had significantly lower BDI scores
(mean BDI‫ )3.5ע6.6ס‬than those who
stated they were depressed (mean
BDI‫ ;2.41ע7.32ס‬Wilcoxon rank-sum statistic, S‫ ;00.832ס‬PϽ0.001). Also, subjects
who stated that they did not need care
for depression had significantly lower
BDI scores (mean BDI‫ )2.5ע5.7ס‬than
those who provided different reasons (e.g.,
337

Psychiatry Outpatients and Depression

lack of transportation, cost, lack of efficacy of treatment) to explain their lack of
utilization of outpatient services (mean
BDI‫ ;9.51ע1.12ס‬Wilcoxon rank-sum statistic, S‫ ;05.722ס‬PϽ0.05).
Finally, in terms of willingness to reengage in treatment, nonparametric analyses demonstrated that patients who were
interested in resuming outpatient services
for depressive symptoms had significantly
more outpatient visits to-date (mean number of visits‫ )1.31ע0.91ס‬than those patients who were unwilling to seek future
psychiatric care for depression (mean
number of visits‫ ;2.3ע8.4ס‬Wilcoxon
rank-sum statistic, S‫ ;00.54ס‬PϽ0.05).

DISCUSSION
First, as described previously, patients who
were referred from a general-medical
healthcare source had fewer visits to the
UBHC geriatric psychiatry program. These
healthcare sources (e.g., internist, family
practice physician) may have been providing treatment for mental health problems.
Non-healthcare sources may have provided
needed encouragement and frequent reinforcement to a patient utilizing outpatient
services. Furthermore, patients may receive support in the form of transportation
or financial assistance from their nonhealthcare referral sources. Consistent
with this idea is the statistically significant
finding of a greater number of visits by married individuals.
Former patients were questioned
about their perception of why treatment
ended. It was not surprising that transportation was cited as a barrier to utilization
of outpatient services because the transportation services in the geographic region
covered by the present study (e.g., Dial-ARide, Medicaid transportation, countywide transportation) are limited. Patients
are restricted to specific days of the week
and specific hours of the day in which they
338

can access these transportation services.
Also, patients may be placed on a 3- to 4week waiting list for appointments, and
some transportation services are operated
on a fee-for-service basis. In addition to
these restrictions, it is also possible that
some of the older adults in our study had
been unaware of the transportation options available to them.
Interestingly, cost was cited as a barrier to utilization of mental health services
in the present study. As a community mental health center, UBHC used a sliding fee
scale, and no one was excluded because of
inability to pay. Although the actual visits
to UBHC were not costly, it may be the associated costs that caused patients to terminate treatment (e.g., cost of transportation, parking, and medication).
Another reason cited by patients for
terminating outpatient sessions was lack of
treatment efficacy. Some patients stated
that their underlying problems could not
be remedied through the treatment received at the clinic. For example, the loneliness resulting from bereavement requires
a change in the patient’s daily routine to
include more social and community interactions. Appropriate encouragement and
guidance by friends, family, and sources
such as outreach services may be needed
in order for some patients to become involved.
With respect to future utilization, patients who had a higher total number of
visits while utilizing services at UBHC were
found to be more willing to seek future
psychiatric care. A possible explanation for
this finding includes satisfaction with improvement in mood experienced as a result of treatment and increased knowledge
about when outpatient care is appropriate.
This brief report has several methodological limitations. Patients with major depression were selected on the basis of their
termination from active treatment for a disorder that needs chronic monitoring in an
elderly population. The study then investigated the issues of access to and utilizaVOLUME 6 • NUMBER 4 • FALL 1998

Aupperle et al.

tion of mental health services. This is
clearly not a purely prospective longitudinal study of geriatric individuals seeking
treatment for major depression. Generalizations from this study are also limited by
the lack of a structured diagnostic instrument, the unique demographics of the cohort, and the characteristics of the setting
within which they were treated.
The sample size also constrains the
study’s conclusions. Although those individuals not included in the identified cohort did not differ statistically from those
included, the study still has the potential
for Type II error and limited power. Despite these inherent limitations, this study
did reveal several findings that have clinical
relevance.
Future prospective studies focusing
on patterns of utilization and individual
patient characteristics should include appropriate outcome measures (based on
patient-reported or observer-rated data)
scored upon admission, termination, and

at regular intervals throughout the treatment period. Incremental administration
will allow for assessment of changes in the
severity of depression throughout the
course of treatment. These changes can be
correlated with total utilization and may
prove useful in better understanding and
predicting utilization patterns. Similarly, an
assessment of general and psychiatric
healthcare utilization before patients’ engagement with services, as well as after termination, would be helpful in characterizing longitudinal patterns. Finally, future
studies should examine the role of outreach services in older adults’ utilization of
mental health care. The number of contacts made with patients by an outreach
service may prove to be a useful variable
for predicting treatment utilization.
Partial support for this study was provided by the Foundation of the University
of Medicine and Dentistry of New Jersey
(UMDNJ).

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