Complementary and Alternative Medicine for Older Adults with Depressive Symptoms:
Analyzing Data from the 2012 National Health Interview Survey
Dr. Ryan Harrison, Psy.D.
University of the Rockies
School of Organizational Leadership
555 East Pikes Peak, Colorado Springs, CO 80903
Phone: (909) 392-4392
This study explored how older adults with symptoms of depression relate to Complementary and Alternative Medicine (CAM) therapies. Data from the 2012 National Health Interview Survey were analyzed to reveal the frequency of distinct CAM therapies’ use among depressed older adults, as well as subjective measurements of CAM therapy helpfulness in this population. Some CAM therapies such as natural supplements, chiropractic/osteopathic treatment, massage, yoga and acupuncture are utilized more commonly than others by older adults with symptoms of depression. Similarly, some CAM therapies are also subjectively determined to be more helpful than others in managing symptoms of depression. The major findings of this study suggested that some CAM therapies are used with greater frequency than others by older adults experiencing symptoms of depression. In addition, some CAM therapies are also perceived to be more helpful than others in terms of depression care and management.
older adult depression, complementary and alternative medicine, frequencies, National Health
Although research has shown that depression is not an inevitable part of growing older, it does remain one of the most common mood disorders experienced by older adults (Centers for Disease Control and Prevention [CDC], 2012b; Geriatric Mental Health Foundation [GMHF], n.d.; National Institutes of Mental Health [NIMH], n.d.). The literature is replete with data describing both risk factors for depression in the older adult population and the multiple adverse health effects of depression. At the same time, diagnosing depression in the elderly population can be difficult for several reasons. This has implications for treating this population, and research suggests that many depressed older adults go undiagnosed or under diagnosed and, therefore, untreated (Lakey et al., 2012; Wancata, Alexandrowicz, Marquart, Weiss, & Friedrich, 2006).
In general, standard treatment of depression for older adults places greater emphasis on prescription medications than on psychotherapeutic approaches (Wancata et al., 2006). In some cases, the two are combined to significant effect (Blazer, 2003; NIMH, n.d.; Rojas-Fernandez & Mikhail, 2012). Paradoxically, even when seemingly adequate treatment is available to depressed older adults, rates of compliance and adherence may be low. Ivanova et al. (2011) found that physicians are more likely today than in earlier eras to prescribe antidepressants. Many older adults resist diagnosis and treatment and are willingly noncompliant with medical treatment. Bosworth, Voils, Potter, and Steffens (2008) reported that as many as 20% to 80% of depressed older adults who are prescribed medications fail to adhere to their medication protocols one month later. There may be additional reasons for medical noncompliance, including adverse side-effects caused by medications, the lack of a complete understanding of the benefits and risks associated with such treatment, cost concerns, alternate recommendations made by others, or preference for therapies that meet the patient’s more holistic needs (Bomar, 2013; Bosworth et al., 2008; Jin, Sklar, Oh, & Li, 2008; Tait et al., 2013).
Depression may itself predispose older adults toward poor medication compliance, including the under-use of medications or inappropriate discontinuation of the medication (Lutwak & Dill, 2012). Problems with memory and cognition, poor vision or hearing, lack of social support, inadequate access to medication, economic burden, difficulty swallowing pills and the lack of dexterity or strength required to open drug containers or handle small pills may also predispose older adults to poor medical compliance (Jin et al., 2008).
However, non-adherence to medical care does not necessarily equate inaction on the part of older adults coping with depression. Research suggests that a significant number turn toward CAM therapies (Astin, Pelletier, Ariane, & Haskell, 2000; Barnes, Bloom, & Nahin, 2008). The suggested prevalence of CAM use among depressed older adults varies widely, although there is growing consensus in literature that it is steadily increasing. In their study of CAM use in the elderly population, Astin et al. (2000) reported that 41% of a sample of older adults reported using CAM within the prior year. Of these, 59% reported mood disorders such as depression while 80% reported improvement in their symptoms following CAM use (Astin et al., 2000).
A 2007 iteration of the NHIS, which included a CAM supplemental questionnaire, revealed growing use of CAM by older adults (Barnes et al., 2008). Additional research utilizing the 2007 NHIS data found that older adults with chronic conditions including depression were more likely to use CAM than their healthier counterparts (Tait et al., 2013). Certain health characteristics do contribute independently to CAM usage. Three of these characteristics, strongly supported by research, are chronic conditions, comorbidity, and depression (Bishop & Lewith, 2008; Eisenberg et al., 1998; Keaton et al., 2009; Nahas & Sheikh, 2011; Park, 2013; Qureshi & Al-Bedah, 2013; Varteresian, Merrill, & Lavretsky, 2013). Older adults often experience one or more of these predisposing factors suggesting there may be a significant numbers of older adults who are using CAM therapies specifically for treating depression and depressive symptoms.
Discerning precise statistics of older adult CAM usage is confounded, however, by low levels of CAM use disclosure. Numerous studies have found that as many as 38% – 60% of instances of CAM usage are not discussed with medical doctors or health care practitioners (Eisenberg et al., 1998; Nemer & McCaffrey, 2010; Willison, Williams, & Andrews, 2007). The result is an inaccurate understanding of how many depressed older adults are using CAM therapies and how effective those CAM users find the therapies to be. The data collected via the 2012 National Health Interview Survey (NHIS) and its CAM supplemental questionnaire can provide recent data that can be used to address these questions.
Study Data and Study Participants
The sample for this study consisted solely of participants in the 2012 NHIS Sample Adult survey and its CAM supplemental questionnaire. Only data from respondents who indicated being 65 years of age or older were used. The 2012 NHIS procedures were designed to collect data representative of the national population. Accordingly, individuals aged 65 and older who were African American, Hispanic, or Asian had increased odds of being selected as the sample adult from each household (CDC, 2012a).
The NHIS is a cross-sectional household interview survey with sampling and interviewing occurring continuously throughout the year (CDC, 2012a). According to the Centers for Disease Control and Prevention (CDC, 2012a), the NHIS sampling plan “follows a multistage area probability design” (para. 7) that is redesigned after every census. For the 2012 NHIS, 428 primary sampling units (PSUs; consisting of counties, contiguous counties, or metropolitan areas) were drawn from all 50 states and the District of Columbia. Within each PSU, 4 to 16 addresses were used. For the adult sample of the 2012 NHIS, one civilian adult per family was randomly selected to self-report responses to survey questions, including those asked as part of the CAM supplement. Because there were no identifiers associated with the NHIS data, and because the dataset was free to download and use in the public domain no official permission was required to utilize the data.
As illustrated in Table 1, of the 14,438 older adults sampled, 7,935 of those provided complete data, including gender. Over 1,000 of the older adults indicated that they had been told by a health professional that they had depression. Although 45% of the sample was missing gender-related data, 32% were coded as female and 22% as male. The majority of the sample adults were Caucasian (44%), with African American being the second most prevalent reported ethnicity. Table 1 indicates common demographics of this sample of older adults.
Indian (American), Alaska Native
Primary race not releasable
Multiple race, no primary race selected
Note. Data from 2012 National Health Interview Survey Sample Adult questionnaire and complementary and alternative medicine questionnaire.
Research Questions and Study Design
In this study, there were two research questions: (1) Which CAM therapies do depressed older adults use most commonly, as evidenced by a higher frequency of self-reported CAM use via the 2012 NHIS? and (2) Which CAM therapies do depressed older adults find most helpful for treating their mood disorder, as evidenced by a higher frequency of self-reported CAM therapies used for treating depression via the 2012 NHIS?
This correlational and quantitative study used frequencies of data from the 2012 NHIS to determine to which CAM therapies older adults with depressive symptoms utilized most commonly and which they found most helpful for managing their condition. The NHIS CAM supplemental questionnaire invoked the term “CAM” to refer to 23 distinct therapies about which survey participants were asked directly. These therapies included: chiropractic/osteopathic medicine, massage, acupuncture, energy healing therapy, naturopathy, hypnosis, biofeedback, ayurveda, chelation therapy, craniosacral therapy, natural supplements, homeopathic treatment, meditation, mindfulness based therapy, guided imagery, progressive relaxation, yoga, tai chi, qi gong, the Feldenkrais method, the Alexander technique, Pilates, and Trager psychophysical integration.
To answer the first of these research questions, regarding which CAM therapies depressed older adults used most commonly, frequencies were generated regarding the occurrence of specific CAM therapy use by older adults whose reported depressive symptoms were greater than zero. Out of 7,889 older adults with depressive symptoms (indicated by responding in the affirmative to one or more of a range of NHIS items coded for symptoms of depression), the highest occurrence of CAM therapy use was natural supplements with 1,390 users. This was followed by 612 participants who used chiropractic or osteopathic manipulation, 351 who used massage therapy, 294 who used yoga and 142 who used acupuncture. These most commonly used CAM therapies are reflected in Table 2. This dataset represented survey respondents who answered the questions about CAM therapy use in the affirmative.
CAM Therapies Used Most Commonly by Depressed Older Adults
Type of CAM therapy
|# of users||% of users|
To answer the second research question, regarding which CAM therapies depressed older adults find most helpful for treating their condition, frequencies were calculated by filtering for depressive symptoms greater than zero and CAM therapy use greater than zero, based on three NHIS items that asked respondents which CAM therapies were their top three most important for addressing their health problem.
The top five CAM therapies reported by older adults with depressive symptoms as most helpful for addressing their health condition were chiropractic/osteopathic therapy (325), supplements (133), massage (117), acupuncture (65) and mind-body therapies (48). Of those who reported using therapies for managing their health condition, between 78.5% and 95.8% said that the therapy helped “some” or “a great deal.” This is illustrated in Table 3.
CAM Therapies Deemed Most Helpful by Depressed Older Adult CAM Users
|Type of CAM therapy||# who found therapy to help “some” or “a great deal”||# who listed therapy as 1 of 3 top choices||% who found the therapy to help “some” or “a great deal”|
Both research questions, answered by descriptive statistical analysis, revealed similar findings. More specifically, the five CAM therapies most commonly used by depressed older adults were found to be similar to those they found most helpful for treating or managing their health condition, with one exception. Mind-body therapies were felt to be more helpful than yoga and those findings may lay the groundwork for a number of additional research studies.
The first research question concerned the CAM therapies which older adults with depressive symptoms use most commonly. As illustrated in Table 2, there were a combined 2,789 responses indicating use of one of five CAM therapies. This number was generated by filtering the dataset to find data from older adults with depressive symptoms who also reported CAM therapy use (n = 7,889). The most commonly used CAM therapy was found to be non-specified natural supplements, followed (in order) by chiropractic/osteopathic, massage, yoga and acupuncture. Although additional CAM therapy usage was reported, the 142 positive responses related to acupuncture represented 1.8% of the sample; smaller results were deemed unnecessary for inclusion in the list of most common therapies. Overall, this analysis revealed there is a general trend in the selection of CAM therapies by depressed older adults.
These findings provide current support for what previous research has uncovered. A number of resources suggest that the five top CAM therapies resulting from an analysis of 2012 NHIS data are also among those that adults and older adults have used most commonly for many years (Astin et al., 2000; Lavretsky, 2009; National Center for Complementary and Alternative Medicine [NCCAM], 2013; Nemer & McCaffrey, 2010; Okoro, Zhao, Li, & Balluz, 2013; United States Department of Health and Human Services [USDHHS], 2011). Indeed, research from the 2002 and 2007 iterations of the NHIS revealed similar results for the older adult population, suggesting a strong preference for natural supplements, acupuncture, chiropractic, massage and yoga (Barnes, Powell-Griner, McFann, & Nahin, 2004; NCCAM, 2013; Nemer & McCaffrey, 2010; Upchurch et al., 2007).
The answer to the second research question, regarding which CAM therapies depressed older adults found most helpful, was represented by Table 3. The dataset suggested that the majority of CAM users found the therapies they used to be helpful either somewhat or a great deal. This information was acquired by compiling data from older adults with depressive symptoms who used CAM and who answered a series of questions regarding their top three CAM therapies used to address their health problem.
The findings were similar to those resulting from the first research question. The CAM therapies deemed most helpful also tended to be those that were most commonly used. One exception was that yoga, which was a frequently utilized CAM therapy, was not one that was found to be among the most helpful. Mind-body medicine appeared to take yoga’s place. Further, mind-body medicine was found to have the highest degree of helpfulness, compared to other therapies, with a 95.8% response indicating helpfulness. It should be noted, however, that this high degree of helpfulness was reported by only 48 individuals, representing fewer than 0.01% of the sample (n = 7,889).
The findings of this study were supportive of conclusions reached by earlier research. For example, the connection between depressed individuals and the therapeutic application of mind-body practices is not new; a study by Meeks and Jeste (2007) found that depressed older adults in a geriatric psychiatric clinic reported greater use of mind-body CAM therapies than other subpopulations. Earlier, Astin et al. (2000) conducted a survey of CAM therapy usage by 728 older adults in California, 80% reported receiving substantial benefit from the CAM therapies to which they turned. Similarly, Cerino (2005) reported on a survey by the National Institutes of Health, which found that a majority (55%) of adults turned to CAM therapies for the perceived helpfulness of the therapies.
The present research study determined that, after mind-body therapies, chiropractic/ osteopathic (88.3%) and massage (84.6%) produced the next highest percentages indicating helpfulness, with natural supplements—the most commonly used CAM therapy—deemed helpful by 82.0% of respondents and acupuncture by 78.5%. As mentioned earlier, however, it should be noted that this represented data provided by only 688 respondents, or 8.72% of survey respondents with depressive symptoms (n = 7,889) who used CAM over the prior 12 months.
There were several limitations in this study. One includes the subjectivity of the NHIS. Although the NHIS is a respected source of public health information, it’s nature as an interview schedule produces nonstandardized responses. Many of the questions are subjective in nature such as the degree in which a CAM therapy was experienced as helpful. While subjectivity is useful in qualitative research for measuring perspective and point of view, in quantitative research, it can have a confounding effect, making it a variable that should be controlled if possible (Drape, 2002; Mackellar, n.d.). It should be noted that the NHIS includes subjective questions making some of the findings of this study unreliable.
In relation to the subjectivity of the NHIS, a second limitation of the current study is the necessary weight given to individual respondents’ personal understandings, beliefs and biases toward CAM therapies. For example, there is little within the NHIS that helps a person understand what the different CAM therapies are or how they are used in practice. As a result, respondents’ answers to items about CAM therapies could only be made from personal experiences. If an individual had been exposed to CAM therapies by poorly prepared practitioners, the resulting answers to CAM-related items would have been unduly skewed. This lack of standardization of knowledge and experience with CAM therapies may also contribute to unreliable findings.
The relative homogeneity of the study may represent another limitation. Although some research suggests that depression is more common among minority groups than among white people (Dunlop, Song, Lyons, Manheim, & Chang, 2003), conflicting research suggests that the prevalence of major depressive disorder (MDD) may be higher in white people than in minority groups(Riolo, Nguyen, Greden, & King, 2005). One common perspective, however, is that non-white, depressed older adults tend to seek treatment less readily than their white counterparts (Conner et al., 2010; USDHHS, 2011). This may be reflected in the dataset resulting from the 2012 NHIS. The majority of survey respondents were white (80%), suggesting that this study may not have captured significant data related to minority use of CAM therapies.
An additional limitation has to do with the design of the study. This research project concerned depression, for which there are a number of standardized reliable and valid screens or interview schedules. All of the data used for this study came from the NHIS. Although the NHIS included the World Health Organization’s Composite International Diagnostic Interview Short Form (CIDI-SF) since 1999, as a survey, the NHIS is not considered a standalone depression scale (Egede, 2004; Kessler, 2007). The items from the NHIS coded for a correlation to depression do relate to commonly known depressive symptoms (feeling sad, hopeless, worthless, etc.). However, the data used for this study related to the incidence of depressive symptoms were subjective in nature.
The NHIS’s CAM supplemental questionnaire’s approach to the topic of natural supplements presented a confounding factor, as well. Although it is well-known that there are many distinct natural supplements, as well as synergistic combinations of supplements that are advertised as helpful for mood stabilization (including ingredients such as St. John’s Wort, l-theanine, lemon balm, SAMe), the CAM supplemental questionnaire allowed respondents to select simply “natural supplements” as a distinct CAM therapy used within the prior year, without necessitating more specificity. Because natural supplements, as a whole, comprise any number of vitamins, minerals, herbs, or other natural substances, its designation as a distinct CAM therapy can be considered a limitation insofar as it obfuscates more precise accounting of active compounds. The degree of this limitation is quite clear when “natural supplements” was found to be the CAM therapy most commonly used and one of the five CAM therapies deemed most helpful by older adults with depressive symptoms. Not knowing which specific supplements were used by this population renders these particular findings somewhat negligible.
Finally, while data analysis revealed which CAM therapies depressed older adults used most commonly and which they found most helpful, these findings do not constitute a list of CAM therapies that have been rigorously tested for their utility in treating depression in older adults, and should be considered grounds for additional research.
Implications for Theory, Practice, and Future Research
There are several implications for theory, practice and research resulting from this study. First, the results of this study underscore what previous research has uncovered. Older adults living in the United States tend to turn toward some CAM therapies more readily than others. Concurrently, there is some indication that the degree of scientific research into specific CAM therapies and their utility in treating depression is not a factor that drives older adults to CAM therapy use. Barnes et al. (2008), for example, discovered that “there is no meaningful correlation between the number of published studies of a CAM therapy and its use by the American public” (p. 7). The implication, supported by this current study, is that additional research needs to be conducted in order to discern precise reasons for the popularity of some CAM therapies over others in the older adult population. Perhaps some reasons include the broader availability of some therapies over others, differences in cost, health insurance coverage, perceived variations in helpfulness, differences in the awareness of available CAM therapies, or internalized value judgments about specific CAM therapies. Additional research is needed to discern whether these reasons, or others, bolster the popularity of some CAM therapies over others in this specific population.
Such research would support theories of CAM use by older adults that have already been suggested in the literature. For example, a number of sources report a variety of reasons why older adults turn to CAM. These include recommendations from health care providers, recommendations from friends, family, or coworkers, displeasure with conventional care approaches and the cost of conventional medicine. Other reasons include desire for general health improvement, need for pain management, desire for increased health autonomy, fear of side-effects from conventional medicine and desire for a more holistic approach to well-being (Astin et al., 2000; Bomar, 2013; Tait et al., 2013). Thus, the results of this study support some previously reached conclusions while also giving emphasis to the need to further research the validity of proposed theories regarding the intersection of older adults’ use of CAM.
The implications of this research on potential changes in practice are modest. In part, this is due to the nature of the study, which was not designed to elicit causal relationships. However, given the large sample used in this study, the growing relevance of CAM therapies in the United States, and a changing perspective toward CAM therapies in the approaching older adult population (AHA, 2007; Cerino, 2005; Sioux, 2011; Varteresian et al., 2013), some suggestions can be made. For example, although it is now common for therapists or other health care practitioners treating older adults to ask about CAM use to avoid negative treatment interactions and to produce a clear picture of overall care, professionals working with older adults with prior depression would have an additional reason for making such an inquiry. Namely, knowing which CAM therapies depressed older adults find most helpful may be of use to practitioners who are less well-acquainted with CAM therapies in general. Health care professionals who exhibit some expectancy that depressed older adults may be using CAM therapies may increase the likelihood within the clinical setting of CAM use disclosure, which has been difficult to determine (Eisenberg et al., 1998; Nemer & McCaffrey, 2010; Willison et al., 2007).
Further, clinicians can use the results of this study to inform their own research into the most common and helpful CAM therapies for their depressed patients. This would have the dual benefit of familiarizing the health professionals with CAM therapies that might otherwise be considered inconsequential and also providing a research-based understanding of which sound integrative health care recommendations could be made.
Finally, should an older adult with depression ask for a recommendation of a CAM therapy, health care providers would be able to give a list of those therapies that other depressed older adults most commonly use as well as which therapies they find most helpful. Even if the CAM therapies in question do not exert the kind of strong effects hoped for by either the practitioner or the patient, this would still represent an advance in practitioner-patient dialogue about the topic of CAM use.
As a result of this correlational study, several recommendations for further research can be made. Studies could shed light on more precise relationships between each of the CAM therapies that depressed older adults use and find helpful and said therapies’ effectiveness. Randomized, controlled, double-blind studies of distinct CAM therapies used for preventing recurrence of depressive symptoms or for treating depression in older adults have been conducted. However, sample sizes tend to be small and such studies typically suffer from weaknesses in research design. Correcting these limitations would constitute meaningful research. Conducting a comparison analysis of the results of similarly scientifically strong studies could help determine the relative utility of some CAM therapies over others in relationship to older adult depression.
Additionally, a qualitative study regarding the reasons why depressed older adults self-select certain CAM therapies over others could yield important insights. Such a study may reveal whether there are some CAM therapies that have correlating stigmas attached to them, discouraging their use and whether cultural familiarity with distinct CAM therapies increases the use of some therapies over others. The degree to which marketing campaigns influence CAM therapy selection and use may be a factor as well. These findings would solidify a growing understanding of the complex relationship between CAM therapies and older adults’ health and wellness behaviors.
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Dr. Ryan Harrison, Psy.D., DAAIM, CWP, is the Director of Resident Life & Wellness at Hillcrest, a continuing care retirement community in Southern California. After having practiced privately as a board certified health and wellness consultant for over ten years, Ryan completed his doctorate in Health & Wellness Psychology at the University of the Rockies, where he focused his research on the intersection of older adult health and well-being and Complementary and Alternative Medicine. He currently leads a team of dedicated staff to optimize older adult health, fitness and wellness.