Last week marked both Mental Health Awareness Week and Dying Matters Awareness Week. These two separate campaigns run annually and, respectively, promote good mental health and the importance of talking about dying, death and bereavement. For our blog this week, our Manager Mark Steedman explores the challenge of addressing mental health in the elderly, including the impact associated with the stigma involved in talking about the problem, linking it to his experiences and interests in mental health and end-of-life care research.
Tackling the stigma around mental health in the elderly and those at the end-of-life
In my previous role at Imperial College, I spent a lot of my time working on health policy research around end-of-life care. One of the first things I learned is that there is stigma in talking about death and dying. It’s intimidating. Many people are afraid to talk about death, to the extent that people fail to plan for the future – nearly two thirds of adults in the UK do not have a will.1 Far fewer have an advance care plan, which can help ensure patients’ wishes are known and respected at the end of life, even if the patients are unable to express their wishes or lose their ability to make decisions.2
Similarly, there is also stigma around mental health, which we illustrated in our recent report At a tipping point? Workplace mental health and wellbeing. One in four people experience a mental health problem at some point in their life, yet there are wide inequalities in access to mental health care. Many people's mental health problems are made worse by the stigma and discrimination they experience from society, but also from families, friends and employers.3 Although 70 per cent of people with a mental health problem eventually fully recover,4 many individuals are afraid to speak up about their mental health out of fear that they will be ostracised at work or face long-term negative repercussions in their career.
The parallels between the stigma around mental health and end-of-life care have resonated with me for some time, and when I realised that both Mental Health Awareness Week and Dying Matters Awareness Week were the same week, I was inspired to research the links between the two areas.
It’s accepted wisdom that our population is getting older. As our report on Better care for frail older people: Working differently to improve care showed, the population of over 75s in the UK increased from 4.4 million in 2001 to 4.9 million in 2010 and is projected to double in size by 2040. Similarly, those over 85 are the fastest growing segment of the population.5
As we age, many people develop long-term conditions such as heart disease, diabetes, hearing loss and osteoarthritis that affect their daily lives, and often people suffer from multiple conditions simultaneously. Many older adults also lose their ability to live independently due to factors such as limited mobility, chronic pain and frailty. Older adults are more likely to experience bereavement, loss of socioeconomic status due to retirement and disability, which can result in isolation, loss of independence and loneliness. Older adults are also more vulnerable to physical, sexual, psychological, emotional, financial and material abuse, as well as abandonment, neglect, and serious losses of dignity and respect.6 There is no question that these types of physical ailments, stresses and changes in quality of life can also have serious psychological repercussions.
At the end-of-life, particularly for people diagnosed with a terminal illness, depression can manifest at any time. However, onset can often occur after initial diagnosis or as the disease advances, often coinciding with increases in pain, and resulting in a decrease in a person’s independence. The anxiety caused by the fear of dying can also often lead to depression, which can make their condition worsen.7
Yet many mental health problems in the elderly and those at the end-of-life are overlooked or misdiagnosed, and the aforementioned stigma hasn’t gone away – people affected are still afraid to speak up.8 In over 65s, about 22 per cent of men and 28 per cent of women are affected by depression,9 and yet it is estimated that 85 per cent of these individuals do not receive any support or care from the NHS.10
Where these numbers manifest most tragically is through suicide. In 2012, the overall suicide rate in the UK for those 70 and over was 6.3 per 100,000.11 While these numbers are low compared to many other countries – for example in the United States it was 16.5 and in South Korea it was a staggering 116.2 – suicide prevention among the elderly is a preventable tragedy and should be a priority in the UK as well as around the globe.
So how do we overcome the stigma around mental health in the elderly and combat these figures?
In 2014, the World Health Organisation (WHO) produced a report on Preventing suicide: A global imperative that laid out nine areas of strategic action for ministries of health: engage key stakeholders; reduce access to means; conduct surveillance and improve data quality; raise awareness; engage the media; mobilise the health system and train health workers; change attitudes and beliefs; conduct evaluation and research; and develop and implement a comprehensive national suicide prevention strategy.12
More recently, in 2016 the WHO provided guidance specifically for treatment and care, including four ways to meet the specific needs of older adults:
- training for health professionals in care for older persons
- preventing and managing age-associated chronic diseases including mental, neurological and substance use disorders
- designing sustainable policies on long-term and palliative care
- developing age-friendly services and settings.13
Promoting active and healthy ageing in ways that ensure older adults have their basic needs met were also presented, including: providing security and freedom
- adequate housing through supportive housing policy
- social support for older generations and their caregivers
- health and social programmes targeted at vulnerable groups such as those who live alone and rural populations or who suffer from a chronic or relapsing mental or physical illness
- programmes to prevent and deal with elder abuse
- community development programmes.14
Finally, the following interventions were recommended:
- early diagnosis, in order to promote early and optimal management
- optimising physical and psychological health and well-being
- identifying and treating accompanying physical illness
- detecting and managing challenging behavioural and psychological symptoms
- providing information and long-term support to caregivers.15
As an individual, I decided I also needed to do my part. I took a course on mental health first aid through Mental Health First Aid England. Although this course mainly focused on mental health in the workplace, the lessons were applicable to numerous situations, including any interactions I may have with older adults. I learned to spot the early signs of a mental health issue; gained more confidence helping someone experiencing a mental health issue; learned how to provide help on a first aid basis; learned how to help prevent someone from hurting themselves or others; learned to help stop a mental health issue from getting worse; learned how to help someone recover faster; and I learned how to guide someone towards the right support. Applying these techniques all work toward overcoming the stigma of mental health problems. In addition to all of this, I’m engaging in my own mental health. I’m speaking up about mental health. And I’m prepared to support my colleagues, friends and relatives if needed. I hope they will all do the same.
5 Later Life in the United Kingdom, Age UK Fact sheet, February 2014.