PERCEPTIONS, ATTITUDE AND PRACTICES TOWARD ELDERLY DEPRESSION AMONG PRIMARY HEALTH CARE PHYSICIANS, RIYADH, SAUDI ARABIA

Background : Elderly people need care services in particular to maintain a high quality of life and health status. Managing the health needs of geriatric patients is part of the continuity of care family physicians provide to their patients. Aims: to assess physicians' attitude, perception and practice toward depression in elderly in primary care sitting. Methodology : A cross- sectional study to assess primary health care physicians' attitude and perceptions and practices toward depression in elderly patients in primary health care centers of King Saud medical city in Riyadh, kingdom of Saudi Arabia using self-administrated questionnaire Results : We received 210 responses to our questionnaire with response rate of 100 % where 51 % of them were females. Furthermore, 37 % of them have experience in PHC less than 5 years while 32 % have experience for more than 10 years. PHC physicians routinely screen for sleep disturbance (79 %), loss of interest or pleasure (79 %), sad mood (72 %), and decreased energy (63 %) in order to diagnosis of depression. Moreover, we found that 56 % of physicians would use clinical guidelines for diagnosis and treatment of geriatric depression where PHQ-9 was the most reported used to describe continuous variables. Chi- test was used to assess the significance of difference in satisfaction level among different categories. Difference was significant when P value is lower or equal to 0.05.

Primary care physicians have a significant role in management of depression in elderly starting with diagnosis of depression (Qureshi, AlHabeeb and Koenig, 2013). Ability of primary care physicians to reduce the stigma of depression and easier access of patients to these physicians encourage patients to ask primary care physicians other than psychologists (Wijeratne and Harris, 2009;Lino et al., 2014;Shah et al., 2018) and thus depression is managed more effectively when there is collaboration between primary care physician and psychiatrist (Park and Unützer, 2011).
Depression in elderly is different than depression in adults where elderlies usually present with somatic symptoms rather than emotional symptoms and thus some physicians could face difficulties as they may refer these symptoms for being aged leading to being depression without proper diagnosis (Park and Unützer, 2011). However, there are many tools that are used to screen for depression including PHQ-9 and Geriatric depression scale (Phelan et al., 2010). However, a comprehensive clinical interview is essential for all patients to confirm the diagnosis before starting treatment (Colasanti et al., 2010).
Treatment of depression in elderly is challenging for many physicians because of the increased risk of drug interaction, side effect, comorbidities and memory impairment (Ramaswamy et al., 2011). There are many studies that conducted worldwide that showed that physician knowledge and attitude toward depression in elderly would affect the quality of depression management (Park and Unützer, 2011;M Al Qahtani, 2014) where physicians with positive attitude are more likely to participate in depressed patient care (Park and Unützer, 2011). Therefore, in this study we aimed to assess physicians' attitude, perception and practice toward depression in elderly in primary care sitting.

Methodology:-
This was a cross-sectional study to assess primary health care physicians' attitude and perceptions and practices toward depression in elderly patients in primary health care centers of King Saud medical city in Riyadh, kingdom of Saudi Arabia. We included all primary health care physicians working in PHC centers of king Saud medical city, in Riyadh with a total population of 210 physicians working in king Saud medical city Primary health care centers of Ministry of Health (MOH) in Riyadh city. The study was depended on self-administrated questionnaire was adapted from University of Illinois College of Medicine (M Glasser, L Vogels and L Vogels, 2009). The questionnaire was divided into categories: demographic characteristics of physician (age, sex, level of physicians. etc.), attitude and perception section and practice section, then section of barriers and needs of physician for improvement of geriatric care in primary care sitting. Ethical considerations were considered to avoid physical or emotional harm, and to ensure confidentiality and privacy of the collected data. A consent form was given to each subject before filling the questionnaire Date was collected according to the questionnaire, data was entered using MS Excel 2010 where data was coded, and IBM SPSS was used for data analysis. Percentage and frequency were used to describe the categorical variables and mean and standard deviation were used to describe continuous variables. Chi-test was used to assess the significance of difference in satisfaction level among different categories. Difference was significant when P value is lower or equal to 0.05.

Results:-
We received 210 responses to our questionnaire with response rate of 100 % where 51 % of them were females. Moreover, 42 of physicians where Saudi Arabian while 33 % of them were between 31-39 years old and 29 % of them were younger than 30 years old. Furthermore, 37 % of them had experience in PHC less than 5 years while 32 % had experience for more than 10 years. Most of participants were either a practitioner or residents while 14 % were specialist and 7 % were consultants. 18 % of them indicated that they are psychologists or counselors in primary care office and 33 % of them indicated that they had attended a conferences or CME activities, which specifically focus on the health need of older adults (Table 1). In table 2, we found that in order to diagnosis of depression, PHC physicians routinely screen for sleep disturbance (79 %), loss of interest or pleasure (79 %), sad mood (72 %), and decreased energy (63 %), while only 21 % of physicians would screen patients for sexual complaints, and 27 % for pain in diagnosis for depression. Moreover, 4 % of participants indicated that they did not routinely screen for depression. Experience of physicians in years did not significantly affect the main symptoms that physicians would screen for diagnosis for depression however, they interest in mostly all symptoms are increasing with age.
Moreover, we found that 56 % of physicians would use clinical guidelines for diagnosis and treatment of geriatric depression where PHQ-9 was the most reported used tool (28 %) followed by geriatric depression scales (24%). It was found that older participants with longer experience would be restricted to guidelines more than younger participants. Moreover, most of physicians would ask for comprehensive metabolic panel (72 %) followed by brain CT (39 %) and CBC (38 %). Moreover, 71 % of physicians would refer patients with depression to psychiatry and 65 % to CBT instead to prescribe medications including SNRI (29 %), TCA (17 %) and SSRI (2 %) ( Table 3).  Moreover, we found that most of participants were agreed that psychotherapy is less efficacious for the older patient compared to younger patients (96 %) while 91 % of them would not focus on depression before excluded possible organic cause, 84 % reported having high confident in diagnosis of depression in elderly patients, 83 % felt comfortable dealing with the family members of depressed patients and 81 % of them thought that is important to help depressed patients. On the other hand, 85 % of physicians did not thought that elderly patients would expect their primary care physician to deal with depression, while 55 % of them did not think that there is nothing to do with depression, 53 % denied that they were pressured for time to routinely investigate depression in elderly patients (Table 4). Moreover, the main barriers to adequate diagnosis and treatment of elderly depressed patients were rejection of patients to treatment (22 % of them indicated it as major problem) and difficulty for access to mental health care in our community (19 % of them indicated it as major problem). On the other hand, all of physicians agreed that patients' concern about medication side effects would be a barrier in treatment. Experience of physicians did not have a significant effect on thought of physicians about barriers except in one factor of that treatment of depression is stigmatizing where older participants thought that this is not considered a barrier compared to less experienced participants (P=0.045) ( Table 5).  Moreover, we found in table 6, that experience of physicians has no significant effect on their attitude or perception except in three statements. Less experienced physicians thought that their knowledge of diagnosis and treatment of depression is up to date in a significantly more manner than physicians with higher experience are (P=0.002). Furthermore, a higher percent of low experience physicians would agree that they preferred not to use the term of depression than high-experienced participants (P=0.005). Finally, 66 % of physicians with experience between 5-10 thought that family members' information is useful in diagnosis of depression compared with 46 % of physicians with experience lower than 5 years and 39 % of physicians with experience of more than 10 years (P=0.005) ( Table  6).

Discussion:-
Depression is one of diseases that is considered a disabling condition in elderly and have a significant negative effect on the quality of life (Ashwaq Al-ghamdi et al., 2018). Generally, most of elderly with mental problem do not seek help from specialist mental health service providers; therefore, their care will fall upon non-psychiatrists (Liu, Lu and Lee, 2008). Therefore, primary care physicians play a great role in management of depression in elderly patients as they considered the primary access to elderly with depressive symptoms (Qureshi, AlHabeeb and Koenig, 2013). Therefore, it is important for primary care physicians to have the correct knowledge, adequate attitude and practice toward depression in elderly patients. In this study, we aimed to assess physicians' attitude, perception and practice toward depression in elderly in primary care sitting.
In this study, the response rate was 100 % which is higher than response rates reported by other studies of 43. Furthermore, we will discuss the main statement-indicating attitude. We found that 81 % of them thought that is important to help depressed patients which is similar with results of Ashwaq (Ashwaq Al-ghamdi et al., 2018), and study of S Liu who indicated that 94.9 % of physicians thought that it is their responsibility to recognize depressed patients (Liu, Lu and Lee, 2008). Moreover, we found that 96 % of physicians in our results agreed that psychotherapy is less efficacious for the older patient compared to younger patients while 91 % of them would not focus on depression before excluded possible organic cause which similar to the results of Ashwaq which also found that only 50 % of physicians had confident to diagnose depression (Ashwaq Al-ghamdi et al., 2018) which in contrast to our results that 84 % of physicians reported having high confident in diagnosis of depression in elderly patients. In addition, J Bawo find that 61.5 % of physicians have difficulties in diagnosis of depression (James et al., 2012) where similar results reported by other studies (Chikaodiri, 2010;Park and Unützer, 2011). Moreover, the main barriers to adequate diagnosis and treatment of elderly depressed patients were rejection of patients to treatment and difficulty for access to mental health care in our community. Similar results found in study of S Liu who found that 81.4 % of physicians thought that un-compliance of patients with medications (Liu, Lu and Lee, 2008).
There are some limitations in this study. The first limitation is depending on self-reported questionnaire, which may cause some personal bias where some participants chose answers, which make them more moral or knowledgeable which could affect results of the study. Other limitations include that the study had been conducted in one institution therefore; we could not generalize the results in the entire kingdom. Finally, the study did not study the effect of demographic factors in attitude and practice of physicians.
In conclusion, we found that most of physicians in Al Riyadh show high positive attitude toward depression of elderly however, there is some limitations in knowledge about symptoms of depression and restriction to guideline. Main barriers to adequate diagnosis and treatment of elderly depressed patients were rejection of patients to treatment and difficulty for access to mental health care in our community. We recommended repeating the study in different regions of the kingdom in order to be able to generalize the results.