Understanding depression in older adults in Northern Ireland – Ioan Racasan – 2nd Year Social Work

Introduction
To understand how depression affects older people in Northern Ireland (N.I.), the social work profession needs to draw knowledge from psychology, sociology, education, health, political science, and other fields by using theories to describe, explain, and predict social events based on scientific evidence, studies, and research. This paper wants to shine a light on how depression affects older people, looking at its biological causes, psychological effects, and the social context in which they live. Its primary focus is on the psychological approaches’ contribution to understanding and practising social work with older people. Firstly, the paper will provide a contemporary definition of depression and some of the causes and effects of this mental illness on older people in N.I. The second part of this paper will consider several theories from psychology, trying to integrate psychological knowledge with social work practice in working with older adults. It will achieve this by combining different approaches and theoretical orientations from psychology in the study of depression and showcase some limitations in applying these theories from psychology in the social work practice.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies various depressive disorders, the most common being ‘major depressive disorder’ (Arnow, Wroolie and Zack, 2015).
Major Depressive Disorder (referred to herein as “depression”) is defined as the experience of low mood or anhedonia plus at least four more types of depressive symptoms during the same 2-week period that cause clinically significant distress or impairment of important daily functions. It cannot be attributed to a substance’s or another condition’s physiological effects (DSM-5, 2013). According to the DSM-5, symptoms must be present most of the day, nearly every day, for at least two weeks.
DSM-5 provides social workers with a common language necessary to communicate with other professionals. However, social work practice must also be aware of some prevailing criticisms. Some categories of mental disorders and diagnoses lack any ‘semblance of empirical support’ (Robbins, 2014, p.583). Another complaint regards classifying disorders scientifically as unsound and introducing definitions of states that will result in the ‘diagnosticating’ of false positives (Frances, 2012). DSM-5 practice of categorical mental disorders classification has demonstrated poor validity (Bjelland and Dahl, 2008; Insel, 2013; Regier et al., 2013). Those classification systems force people into only two boxes, either sick or healthy.
The U.K. population is ageing exponentially, with the number of people aged 65 and over growing by nearly half in the past 30 years. People living longer is a cause for celebration, but older people are more vulnerable to mental health problems. Depression affects around 22% of men and 28% of women aged 65 years and over or over 40% of older people in care homes (Health and Social Care Information Centre, 2007; Age U.K., 2016), yet it is estimated that 85% of older people with depression receive no help at all from statutory services in the U.K. (Smyth, 2014).
In the last seven years, N.I. has seen a 60% increase in adults diagnosed with depression. In 2018, 1 in 9 adults were diagnosed with depression, a jump from 1 in 15 compared with 2013 statistics (Patient and Client Council Northern Ireland, 2018).
The treatment of depression accounts for a significant proportion of the U.K.’s National Health Service (NHS) annual budget. It is predicted to cost the economy £9 billion in lost earnings by 2026 (Office for National Statistics, 2018).
The National Institute for Health and Care Excellence (NICE) includes clinical guidelines for managing depression in adults. These include psychological therapies followed by or alongside pharmacological treatment. In addition, NICE guidelines make evidence-based recommendations on preventing and managing depression (NICE, 2009).
Effective treatment for depression is essential not only because of the social impact of the condition but also because depression is the leading cause of disability in the U.K. In addition, depression is the most prevalent mental health problem in old age, and the social work practice must recognise these diagnostic criteria (Ray, Bernard and Phillips, 2009).
Social isolation and loneliness, lack of mental stimulation, and physical inactivity in later life increase the risk of poor mental health, including depression, and the risk of mild cognitive impairment and dementia.

Psychological knowledge in the Social Work profession

Psychology has many schools (or models) of thought and applied paradigms (psychodynamic, humanistic, behaviourism etc.). This paper does not intend to provide an exhaustive monograph of all psychological knowledge used in social work. Instead, it aims to critically discuss a few theories and approaches to understanding and practising social work concerning major depressive disorder (depression) in older populations in Northern Ireland (N.I.).
In the psychodynamic approach, depression is a form of grief caused by anger converted into self-hatred, a so-called ‘anger turned inward’. In psychodynamic theory, depressed people can struggle to have a healthy concept of relationships. This may lead them to experience anxiety during interaction with other people (van Eck et al., 1996). One well-known modern subsection of psychodynamic theory is object relations theory. This approach examines how people understand and mentally represent their relationships with others. The object relations theory has the people and the representations experienced and remembered by the person doing the “objectification” at the core. Thus, people’s emotions and moods are close interconnected with the relationships they experience. At the centre of object relations theory is the assumption that early relationships will set the tone for subsequent relationships (Dealey and Evans, 2021).
Depression is precipitated by ‘wrong’ or ‘problematic’ representations of healthy relationships people have. The struggle of maintaining close emotional contact with the ‘object’ (people) develops depression. A person who feels dependent upon relationships with ‘objects’ (others) and grieves over the threatened or actual loss of some relationships will have feelings of helplessness and weakness and experience intense fears of abandonment developing and then acute depression (Gerson, 2021).
The challenge for social work practice is understanding that past experiences can affect current attitudes and behaviours. Psychodynamic principles can improve the social work support in interventions relating to depression by establishing an effective working relationship-based practice (Borden, 2000; Bower, 2005; Turney, Ruch and Ward, 2018).
Humanistic approaches emphasise personal growth, self-determination and the achievement of human potential. With this approach, depression disturbs a person’s ability to grow to their full potential. The sufferer can experience healing if the help is provided with empathy, unconditional positive regard and congruence. The humanistic approach accepts that every individual holds the key to their ability to facilitate change (DeRobertis, 2020). Therefore, we can help a depressed person if the core conditions of empathy, unconditional positive regard and congruence are in place. Then healing can begin to take place.
Social workers must approach service users with empathy, respect and unconditional positive regard, whatever their psychological perspective in the social work practice. They can develop the right conditions for the service users to grow and achieve a higher level of self-acceptance, self-actualisation and self-worth (Robinson, 2021).
The behavioural theory hypothesis is that specific environmental changes and avoidant behaviours hinder individuals from encountering environmental rewards and reinforcement, eventually leading to and perpetuating depression (Carvalho and Hopko, 2011). In behavioural conceptualisations of depression, its development and persistence stem from decreased environmental rewards associated with a reduction in positively reinforced healthy behaviour. Behavioural theories focus on the cycle of reinforcing depression and passive behaviours with the punishment of healthy behaviours (Ferster, 1973; Lewinsohn, 1974; Martell, Addis, and Jacobson, 2001).
Behavioural theory can support social workers in their practice with older people, encouraging them to engage in adaptative behaviours and (re)develop positive, healthy behaviours and lifestyles such as exercise and healthy eating, helping decrease depression (Cameron et al., 2020).
Cognitive psychology mainly involves studying internal “higher mental processes” related to perception, attention, thinking, language, memory, problem-solving, and learning (Lachman, Lachman and Butterfield, 2015) through inferences from behaviour. Cognitive psychology is concerned with these internal processes to make sense of the environment and decide what action might be appropriate (Eysenck and Keane, 2006). The cognitive approach highlights the unseen knowledge and argues that the relationship between stimulus and response is complex and mediated (Eilifsen and Arntzen, 2021; Holland, 2008).
Depressed people have negative thought patterns about themselves and the world and interpret the world accordingly. For example, someone suffering from depression, greeting a friend on the other side of the street and receiving no answer could interpret as being purposely ignored and not worthy of attention. Depressed people seek negative clues that feed their interpretation of the world around them. Thus, they tend to have a negative bias from the outset.
Cognitive Behavioural Therapy (CBT) focuses on how thoughts and feelings influence behaviours and assists people in identifying self-destructive thoughts and behaviours. These cognitive patterns can lead to psychological problems. For example, a depressed person needs to identify their negative automatic thoughts first and then be supported to challenge them.
Competent social work practice mandates that social workers act from an informed and research-based knowledge base when working with older people. Thus, having a good grasp of psychological theories guides the social workers by providing them with a sense of direction, purpose, and control using research-based scientific evidence in theory (Crawford and Walker, 2008).
A comprehensive overview of research on depression is beyond the scope of the current paper. However, a brief discussion of different perspectives of depression will be provided to contextualise it. Extensive research on the aetiology of depression is rooted in psychological, biological and social theories (Dobson and Dozois, 2011).
From a psychological and social perspective, depression will surface from adverse life events. Beck’s cognitive theory of depression hypothesises that depressed or depression-vulnerable people exhibit an increase in attention, interpretation and memory biases for negative stimuli (Dozois and Beck, 2011; Hankin et al., 2009).
The biological perspective shows that the cause of depression could be inflammation in the brain (Berk et al., 2013). Malfunctioning of the brain functions or imbalances of neurotransmitters can be restored with anti-depressants (Drevets et al., 2008).
From an evolutionary perspective, depression is considered a way of adapting to events, such as biasing cognition to avoid losses or disengaging from inaccessible goals (Durisko, Mulsant, and Andrews, 2015).

Social Work with Older Adults in N.I.

Among older people, depression is mainly associated with an accelerated functional and cognitive deficit (Austin et al., 2001; Hammar and Ardal, 2009; Sierksma et al., 2010). Healthcare costs and decreased quality of life due to the early onset of the prodromal symptom of dementing diseases such as Alzheimer’s Disease (Dobos et al., 2010; Panza et al., 2010; Steffens, 2012) and excess mortality (Johnson et al., 2013; Modrego and Ferrández, 2004; Ownby et al., 2006). Consequently, depression has become a leading cause of disability worldwide. Depressive disorders are common among older adults and are the fourth leading cause of global disease and disability burden. Yearly, 25% of the population in Europe suffers from this severe mood disorder (WHO-Europe, 2003).
Østbye et al. (2000) found twice as many women with depression as men, which increases with age. In addition, the cumulative effects of certain types of trauma (e.g., loss of loved ones) are associated with depressive symptoms (Ogle, Rubin and Siegler, 2014), and the ageing process, itself, can exacerbate symptoms and behaviours related to post-traumatic stress (Graziano, 2008).
Corcoran et al. (2013) meta-analysis established that bereavement, relationship stressors and communication difficulties with family members were increased risk factors for depression. Other risk factors stated in research include low educational attainment, financial hardship, lacking social support and physical health problems (Schmitz and Brandt, 2019; Gariépy et al., 2016).
Social work practice models are ways in which social workers implement theories in their practice. This approach provides social workers with the tools to offer their service users effective services in their struggles with depression. Social workers need to use evidence-based theories, which are tried and tested and produce something of a track record that allows them to anticipate, with some confidence, the results of any action they take (Gentle-Genitty et al., 2014).
Competent practice in social work mandates that social workers act from an informed and research-based knowledge base. Therefore, having a good grasp of theory guides the social workers by providing them with a sense of direction, purpose, and control using research-based scientific evidence in theory (Dix, Hollinrake and Meade, 2019).
Social work needs to be practiced under the values of Northern Ireland Social Care Council (NISCC) Standards of conduct and practice and the British Association of Social Workers (BASW) Code of ethics. Those values guide the development of good quality relationships between the social workers and older people by ensuring that social work remains a practice-based profession and an academic discipline promoting social change, empowerment and liberation of people (NISCC, 2019; BASW, 2014).
Social work practices are sustained by values such as promoting human rights with social justice, working in partnership, and protecting welfare steeped in anti-oppressive practice (BASW, 2018). They respect and maintain the dignity and privacy of older people and treat them fairly by promoting equal opportunities, respecting diversity, beliefs, preferences, and cultural differences and challenging discriminatory attitudes or behaviours. Social work commits to its core values of empowerment, anti-discriminatory practice and social justice. This vital profession significantly challenges oppression, social exclusion and structural inequalities.
While some theories provide contributions in explaining and others have a better position in predicting, all these theories have certain limitations, and social work practice needs to be mindful to minimise them. No theory or perspective displayed in this paper addresses depression in older people in a holistic way. The psychological approaches are at different levels of being reductionist or individualistic. They overlook or ignore accounting for the biological, psychological or socio-economic forces that might impact the lives of service users. No single psychological approach holds all the answers to solving the complex problems faced by many older people suffering from depression. The approaches mentioned in this paper have limited application.
The psychodynamic perspective is not based upon sound methodology, and many theoretical ideas can be challenged. For example, the psychodynamic theory criticises its relative lack of testable predictions and is unscientific and unfalsifiable (Grünbaum, 1979). Another critique from a social work perspective is that it is an approach laden with negative value assumptions. From this perspective, the client can perceive the social worker to be in control of interpreting the individual’s depression.
The humanistic approach emphasises subjective experience and is not scientific by not using objective methods, thus not making predictions.
The behavioural theory uses a ‘mechanistic’ view of behaviour, discounting everything else and can make the mistake of focusing upon external variables to such an extent that the particular needs of service users are unmet. Every older person with depression will not react similarly to an external response. The main critique is that the behavioural approach has no scientific certainty.
CBT was considered the gold standard for therapy (David et al., 2018), the most researched form, but most studies only use a small sample. A meta-analysis (Cuijpers et al., 2013) found no evidence to suggest CBT was more or less effective than other psychotherapies when looking at over 100 studies. Doubtless, CBT is effective for adult depression, but the effects could be overestimated.
This paper puts forward the limits of relying on a single theory or approach to explain depression in social work practice is flawed and dangerous for the adult population suffering from depression in N.I.
This paper tries to capture the essence of the contemporary social work environment of supporting older people and argues for a relationship-based profession that uses psychological knowledge to inform interventions. Of course, no single psychological approach will solve the complex problems of older people but drawing on several psychological approaches offers a greater chance of successful outcomes.

Conclusions

The social work profession exists where individuals, communities, and society intersect, so social workers must be a ‘bridge and a link’ in this complex web of relationships. The natural ageing process is mainly associated with physical and emotional vulnerability, and it can increase a person’s need for comfort and safety.
Older people have the right to sensitive and ethical practice, participate in the decisions affecting their lives (Kropf and Hutchinson, 2000), and be engaged in co-production regarding their care (Boland et al., 2021). Moreover, older adults are complicated human beings with problems interconnected with biological, psychological, social and cultural dimensions (Richardson, 2009), which makes social work practice well-positioned to be the ageing competent profession to positively affect their quality of life (Rizzo and Rowe, 2006).
The evidence presented in this paper has shown that having a deep understanding of the psychological, social and biological knowledge of depression makes for a more robust and better social work practice.

References:

Age U.K. (2016) Hidden in Plain Sight: The Unmet Mental Health Needs of Older People. Age U.K. Available at: http://www.ageuk.org.uk/brandpartnerglobal/wiganboroughvpp/hidden_in_plain_sight_older_peoples_mental_health.pdf [Accessed 26 Apr. 2021].  

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5, 5th ed., American Psychiatric Association, Washington DC.

APA Dictionary of Psychology. (2014). [online] Available at: https://dictionary.apa.org/ [Accessed 26 Apr. 2021].  

Arnow, B. A., Wroolie, T. E., and Zack, S. E. (2015). Depressive disorders. In L. W. Roberts and A. K. Louie (Eds.), Study guide to DSM 5. Washington, DC, London, England: American Psychiatric Publishing,

Austin, M. P., Mitchell, P., and Goodwin, G. M. (2001). Cognitive deficits in depression: Possible implications for functional neuropathology. British Journal of Psychiatry, 178(3), 200–206. https://doi.org/10.1192/bjp.178.3.200 [Accessed 26 Apr. 2021].   

Berk, M., Williams, L.J., Jacka, F.N. et al. (2013). So depression is an inflammatory disease, but where does the inflammation come from? BMC Med 11, 200 https://doi.org/10.1186/1741-7015-11-200 [Accessed 26 Apr. 2021].   

Bjelland, I., and Dahl, A. A. (2008). Dimensional diagnostics – new classification of mental disorders. Tidsskr Nor Legeforen. 128: 1541-3

Boland, J., Abendstern, M., Wilberforce, M., Pitts, R., Hughes, J., & Challis, D. (2021) ‘Mental health social work in multidisciplinary community teams: An analysis of a national service user survey’, Journal of Social Work, 21(1), pp. 3–25. https://doi.org/10.1177/1468017319860663 [Accessed 26 Apr. 2021].    

Borden, W. (2000). The Relational Paradigm in Contemporary Psychoanalysis: Toward a Psychodynamically Informed Social Work Perspective. Social Service Review, 74(3), pp.352–379.

Bower, M. (2005). Psychoanalytic theory for social work practice: thinking under fire. London; New York: Routledge.

British Association of Social Workers (BASW) (2014). The Code of Ethics: British Association of Social Workers, Brighton, BASW.

British Association of Social Workers (BASW) (2018). Strategic Social Worker – Professional Capabilities Framework, Brighton, BASW.

Cameron, L. D., Fleszar-Pavlović, S. and Khachikian, T. (2020). “Changing Behavior Using the Common-Sense Model of Self-Regulation,” in Hagger, M. S., Cameron, L. D., Hamilton, K., Hankonen, N., and Lintunen, T. (eds) The Handbook of Behavior Change. Cambridge: Cambridge University Press (Cambridge Handbooks in Psychology), pp. 60–76. https://doi:10.1017/9781108677318.005 [Accessed 26 Apr. 2021].  

Carvalho, J.P. and Hopko, D.R. (2011). Behavioral theory of depression: Reinforcement as a mediating variable between avoidance and depression. Journal of Behavior Therapy and Experimental Psychiatry, [online] 42(2), pp.154–162. Available at: https://www.sciencedirect.com/science/article/pii/S0005791610000984 [Accessed 26 Apr. 2021].  

Corcoran, J., Brown, E., Davis, M., Pineda, M. and Kadolph, J. (2013). Depression in older adults: A meta synthesis. Journal of Gerontological Social Work, 56, 509-534. https://doi:10.1080/01634372.2013.811144 [Accessed 26 Apr. 2021].    

Crawford, K. and Walker, J. (2008). Social work with older people. Exeter: Learning Matters.

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A. and Dobson, K.S. (2013). A Meta-Analysis of Cognitive-Behavioural Therapy for Adult Depression, Alone and in Comparison, with other Treatments. The Canadian Journal of Psychiatry, 58(7), pp.376–385.

David, D., Cristea, I. and Hofmann, S.G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in Psychiatry, [online] 9(4). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797481 [Accessed 26 Apr. 2021].    

Dealey, R., P., and Evans, M.R. (2021). Discovering Theory in Clinical Practice: A Casebook for Clinical Counseling and Social Work Practice. Cham: Springer International Publishing.

DeRobertis, E. M. (2020) ‘The Humanistic Revolution in Psychology: Its Inaugural Vision’, Journal of Humanistic Psychology, 61(1), pp. 8–32. https://doi:10.1177/0022167820956785 [Accessed 26 Apr. 2021].  

Dix, H., Hollinrake, S. and Meade, J. (2019). Relationship-based social work with adults. St Albans: Critical Publishing Ltd.

Dobos, N., Korf, J., Luiten, P. G., and Eisel, U. L. (2010). Neuroinflammation in Alzheimer’s disease and major depression. Biological Psychiatry, 67(6), 503–504. https://doi.org/10.1016/j.biopsych.2010.01.023 [Accessed 26 Apr. 2021].   

Dobson, K. S., and Dozois, D. J. A. (Eds.) (2011). Risk factors in depression. Burlington: Elsevier.

Dozois, D. J. A., and Beck, A. T. (2011). Cognitive schemas, beliefs and assumptions. In K. S. Bobson, and D. J. A. Dozois (Eds). Risk factors in depression (119-142). Burlington: Elsevier.

Drevets, W. C., Price, J. L., and Furey, M. L. (2008). Brain structural and functional abnormalities in mood disorders: implications for neurocircuitry models of depression. Brain Struct Funct. 213, 93-118. https://doi:10.001/s00429-008-0189-x [Accessed 26 Apr. 2021].   

Durisko, Z., Mulsant, B. H., and Andrews, P. W. (2015). An adaptationist perspective on the etiology of depression. Journal of Affective Disorders, 172, 315-323. https://doi:10.1016/j.jad.2014.09.032 [Accessed 26 Apr. 2021].   

Eilifsen, C. and Arntzen, E. (2021). Mediated Generalisation and Stimulus Equivalence. Perspectives on Behavior Science, 44(1), pp.1–27.

Eysenck, M.W. and Keane, M.T. (2006). Cognitive psychology: a student’s handbook. New York, Ny: Psychology Press.

Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28 (10), 857- 870.

Frances, A. (2012). DSM-5 is a guide, not a bible: simply ignore its 10 worst changes.  [online] Available at: https://www.huffpost.com/entry/dsm-5_b_2227626 [Accessed 26 Apr. 2021].    

Gariépy, G., Honkaniemi, H. and Quesnel-Vallée, A. (2016). “Social support and protection from depression: systematic review of current findings in Western countries,” British Journal of Psychiatry. Cambridge University Press, 209(4), pp. 284–293. https://doi:10.1192/bjp.bp.115.169094 [Accessed 26 Apr. 2021].   

Gentle-Genitty, C., Chen, H. and Karikari, I., & Barnett, C. (2014). Social Work Theory and Application to Practice: The Students’ Perspectives. Journal of Higher Education Theory and Practice. 14(1), pp 36-47.

Gerson, G., (2021). Individuality and Ideology in British Object Relations Theory. S.L.: Routledge.

Graziano, R. (2008). Trauma and aging. Journal of Gerontological Social Work, 40, 4, 3-2. https://doi:10.1300/J083v40n04_02 [Accessed 26 Apr. 2021].   

Grünbaum, A. (1979). Is Freudian Psychoanalytic Theory Pseudo-Scientific by Karl Popper’s Criterion of Demarcation? American Philosophical Quarterly, [online] 16(2), pp.131–141. Available at: http://www.jstor.org/stable/20009750 [Accessed 26 Apr. 2021].   

Hammar, A., and Ardal, G. (2009). Cognitive functioning in major depression–a summary. Frontiers in Human Neuroscience, 3, 26. https://doi.org/10.3389/neuro.09.026.2009 [Accessed 26 Apr. 2021].   

Hankin, B. L, Oppenheimer, C., Jenness, J., Barrocas, A., Shapero, B. G., and Goldband, J. (2009). Developmental origins of cognitive vulnerabilities to depression: Review of prosess contributing to stability and change across time. Journal of Clinical Psychology. 65(12), 1327-1338. https://doi:10.1002/jclp.20625 [Accessed 26 Apr. 2021].   

Health and Social Care Information Centre. (2007). Health Survey for England, 2005: Health of Older People. Available at: http://www.hscic.gov.uk/pubs/hse05olderpeople [Accessed 26 Apr. 2021].

Holland, P.C. (2008). Cognitive versus stimulus-response theories of learning. Learning & Behavior, 36(3), pp.227–241.

Insel T. (2013). Transforming diagnosis. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis  [Accessed 26 Apr. 2021].    

Johnson, L. A., Mauer, C., Jahn, D., Song, M., Wyshywaniuk, L., Hall, J. R., Balldin, V. H., and O’Bryant, S. E. (2013). Cognitive differences among depressed and non-depressed MCI participants: A project FRONTIER study. International Journal of Geriatric Psychiatry, 28(4), 377–382. https://doi.org/10.1002/gps.3835 [Accessed 26 Apr. 2021].   

Kropf, N. and Hutchison, E. (2000). Effective practice with elderly clients. In R. Schneider, N. Kroff & A. Kisor. Gerontological social work: Knowledge, service settings and special populations. (2nd. ed.). Belmont, Cal: Brooks/Cole.

Lachman, R., Lachman, J.L. and Butterfield, E. (2015). Cognitive psychology and information processing: an introduction. Hillsdale, N.J.: Lawrence Erlbaum Associates; New York.

Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. J. Friedman, and M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research (pp. 157-178). New York: John Wiley and Sons.

Martell, C. R., Addis, M. E., and Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: Norton.

Modrego, P. J., and Ferrández, J. (2004). Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: A prospective cohort study. Archives of Neurology, 61(8), 1290–1293. https://doi.org/10.1001/archneur.61.8.1290 [Accessed 26 Apr. 2021].   

National Institute for Health and Care Excellence. (2009). NICE – Depression in adults: recognition and management. CG90. London

Northern Ireland Social Care Council (2019). Standards of Conduct and Practice for Social Workers. Belfast (NISCC). [online] Niscc.info. Available at: https://niscc.info/registration-standards/standards-of-conduct-and-practice [Accessed 26 Apr. 2021].   

Ogle, C., Rubin, D. and Siegler, I. (2014). Cumulative exposure to traumatic events in older adults. Aging and Mental Health, 18, (3), 316-325. https://doi10.1080/13607863.2013832730 [Accessed 26 Apr. 2021]. 

Office for National Statistics (2018). Suicides in the UK – Office for National Statistics. [online] Ons.gov.uk. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2018registrations [Accessed 26 Apr. 2021]. 

Østbye, T., Steenhuis, R., Walton, R. and Cairney, J. (2000). Correlates of Dysphoria in Canadian Seniors: The Canadian Study of Health and Aging. Canadian Journal of Public Health, 91(4), pp.313–317.

Ownby, R. L., Crocco, E., Acevedo, A., John, V., and Loewenstein, D. (2006). Depression and risk for Alzheimer disease: Systematic review, meta-analysis, and metaregression analysis. Archives of General Psychiatry, 63(5), 530–538. https://doi.org/10.1001/archpsyc.63.5.530 [Accessed 26 Apr. 2021].   

Panza, F., Frisardi, V., Capurso, C., D’Introno, A., Colacicco, A. M., Imbimbo, B. P., Santamato, A., Vendemiale, G., Seripa, D., Pilotto, A., Capurso, A., and Solfrizzi, V. (2010). Late-life depression, mild cognitive impairment, and dementia: Possible continuum? The American Journal of Geriatric Psychiatry, 18(2), 98–116. https://doi.org/10.1097/JGP.0b013e3181b0fa13 [Accessed 26 Apr. 2021].    

Patient and Client Council Northern Ireland. (2018). Depression in Northern Ireland. The Facts. – Patient and Client Council Northern Ireland. [online] Available at: https://patientclientcouncil.hscni.net/depression-in-northern-ireland-the-facts/. [Accessed 26 Apr. 2021].   

Ray, M., Bernard, M., and Phillips, J. (2009). Critical issues in social work with older people. New York, NY: Palgrave MacMillan.

Regier, D.A., Narrow, W.E., Clarke, D.E., Kraemer, H.C., Kuramoto, S.J., Kuhl, E.A. and Kupfer, D.J. (2013). DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses. American Journal of Psychiatry, 170(1), pp.59–70.

Richardson, V. (2009). Clinical social work with older adults. In A. Roberts. (Ed.), Social workers’ desk reference. New York: Oxford University Press.

Rizzo, V.M. and Rowe, J.M. (2006). Studies of the Cost-Effectiveness of Social Work Services in Aging: A Review of the Literature. Research on Social Work Practice, 16(1), pp.67–73. https://doi:10.1177/1049731505276080 [Accessed 26 Apr. 2021].     

Robbins, S.P. (2014). From the Editor – The DSM-5 and Its Role in Social Work Assessment and Research. Journal of Social Work Education, 50(2), pp.201–205.

Robinson, S. (2021). Priorities for health promotion and public health: explaining the evidence for disease prevention and health promotion. Milton Park, Abingdon, Oxon; New York, Ny: Routledge.

Schmitz, A, Brandt, M, (2019). Gendered patterns of depression and its determinants in older Europeans. Archives of Gerontology and Geriatrics 82, 207–216. https://doi.org/10.1016/j.archger.2019.02.015 [Accessed 26 Apr. 2021].    

Sierksma, A. S., van den Hove, D. L., Steinbusch, H. W., and Prickaerts, J. (2010). Major depression, cognitive dysfunction and Alzheimer’s disease: Is there a link? European Journal of Pharmacology, 626(1), 72–82. https://doi.org/10.1016/j.ejphar.2009.10.021[Accessed 26 Apr. 2021].   

Smyth, C. (2014). Depression in old age ‘is the next big health crisis’. The Times. Available at: http://www.thetimes.co.uk/tto/health/news/article4057224.ece [Accessed 26 Apr. 2021].

Steffens, D. C. (2012). Depressive symptoms and mild cognitive impairment in the elderly: An ominous combination. Biological Psychiatry, 71(9), 762–764. https://doi.org/10.1016/j.biopsych.2012.02.002 [Accessed 26 Apr. 2021].   

Turney, D., Ruch, G. and Ward, A. (2018). Relationship-Based Social Work, Second Edition: Getting to the Heart of Practice. Jessica Kingsley Publishers.

van Eck M, Berkhof H, Nicolson N, Sulon J. (1996). The effects of perceived stress, traits, mood states, and stressful daily events on salivary cortisol. Psychosom Med. Sep-Oct; 58(5):447-58. https://doi:10.1097/00006842-199609000-00007 [Accessed 26 Apr. 2021]. 

WHO-Europe. (2003). Mental health in the WHO European Region. World Health Organization Europe.