Beliefs about mental illness and willingness to seek help: a cross-sectional study

Evidence indicates that older adults underutilize mental health services, but little is known empirically about the perceptions older adults have about mental illness and their attitudes about seeking professional help for psychological problems. The present study examined beliefs about mental illness and willingness to seek professional help among younger (n=96; M age=20.6 years; range=17-26 years) and older (n=79; M age=75.1 years; range=60-95 years) persons. Participants completed the Beliefs Toward Mental Illness Scale and the Willingness to Seek Help Questionnaire. Older adults had generally similar perceptions of mental illness as younger adults except that older adults were more likely to perceive the mentally ill as being embarrassing and having poor social skills. Older adults also did not report a lower willingness to seek psychological help. Correlational analyses showed that, among older adults, increases in negative attitudes about mental illness (specifically, the view that the mentally ill have poor interpersonal skills) are associated with decreases in willingness to seek psychological services. An implication is that negative stereotypes about mental illness held by some older adults could play a role in their underutilization of mental health services. Other barriers to mental health care are also discussed.     

Characteristics of older adults referred to a psychiatric emergency outreach service

Although older adults typically underutilize mental health services, problems associated with dementing illnesses, chronic medical illnesses, affective disorders, social isolation, and multiple medication use, among other phenomena, have increased referrals of the elderly to psychiatric emergency services. The present study reviewed characteristics of elderly adults referred to a psychiatric emergency outreach/screening service. Of all individuals for whom a referral was made, 24% were aged 60 or older. Among those older adults referred, 63% were seen by screening service personnel; 37% did not meet screening criteria or voluntarily sought mental health services. Diagnoses of individuals evaluated included dementia (27%), affective disorders (27%), schizophrenia (16%), psychosis (12%), alcohol abuse (7), and diagnosis deferred (11%). Findings highlight the limited options available for mental health care of the aged.     

Costs of community-based public mental health services for older adults: variations related to age and diagnosis

BACKGROUND: Several studies have examined service use among older adults although, to our knowledge, none has examined costs from a systems perspective. This study examined use and costs of mental health services among older adults in San Diego County in order to determine how expenditures and modes of service varied by age cohort and psychiatric diagnosis. METHODS: Utilization data from San Diego County Adult and Older Adult Mental Health Services (AOAMHS) were used to identify older adults (age > or = 60) receiving services in the community during fiscal year 2003-2004. Cost data were derived from detailed examination of cost reports, and Medicaid fee schedules. Trends in demographic and clinical characteristics by six age cohorts were described. Multivariate models were used to estimate the relationships between costs, age, and clinical diagnosis while controlling for other demographic and clinical characteristics. Components of costs were also examined. RESULTS: Total expenditures declined from age cohorts 60-64 through ages 85 and over. Expenditures were similar, and greatest, for clients with schizophrenia and bipolar disorder, while outlays were lower for those with major depression, other psychotic disorder, other depression, anxiety, substance use disorder, and cognitive disorders. Clients diagnosed with cognitive disorder had high use of emergency services and little connection to outpatient services. CONCLUSIONS: Expenditures were related to age and clinical diagnosis. Future efforts should investigate older adults' pathways to care, and should determine whether older adults presenting in emergency services would benefit from a specialized case management program providing linkages to community based resources.     

Understanding referral patterns to an epilepsy clinic: Professional perceptions of factors influencing the referral of older adults

PurposeThe number of older patients with epilepsy has been increasing steadily, however older adults have been shown to be referred less commonly to specialist epilepsy services than younger individuals. The aim of this study was to explore staff perceptions of why older adults may be under-represented in epilepsy clinics.MethodWe conducted 19 interviews with potential referrers and staff providing services including GPs, geriatricians, neurologists, service and clinical managers and epilepsy nurses. Data were analysed using principles of thematic analysis to identify and examine recurring views and perceptions.ResultsSeven key factors were suggested as leading to under-referral of older adults: patient difficulties accessing hospital; patient reluctance to attend clinics; unclear referral pathway; complex differential diagnosis; gaps in referrer knowledge; the length of time since onset; and particular characteristics of older patients.ConclusionWhile recognising the limitations of the study we believe that it provides valuable further understanding of referral patterns to specialist epilepsy services. Future studies will need to determine whether the assumptions made by the interviewees about the thoughts and wishes of older people with epilepsy were correct or not. To understand this issue more clearly, we plan to sample the views of patients directly. Of particular concern are assumptions regarding older patient's willingness to attend appointments and about the impact of seizures on the life of an older adult.     

Clergy as mental health service providers to older adults

Older adults tend to seek help for emotional problems from clergy at greater rates than they do from other sources. However, their help-seeking from clergy is largely understudied. We used data from the Naturally Occurring Retirement Community (NORC) Demonstration Project to examine older adults' patterns of help-seeking from clergy. We studied a sample of adults aged 65 or older (n = 317) to determine which factors were related to help-seeking from a religious leader. This study was framed within the Behavioral Model of Health Services Utilization. Results of hierarchical logistic regression analyses indicated that having less social support and greater frequency of attendance at religious services was related to help-seeking from clergy for this sample, while other predisposing, enabling, need and religiosity variables were not found to be related to help-seeking from clergy. Discussion focuses on the need for mental health workers to be aware of the important role that clergy play in service provision and to find ways to leverage knowledge and skills to enhance provider-clergy relationships in order to improve services that older adults receive.     

Patient perceptions of the referral of older adults to an epilepsy clinic: Do patients and professionals agree who should be referred to a specialist?

The aim of this study was to establish whether older patients concurred with previously reported staff perceptions of why older adults may be underrepresented in epilepsy clinics. Fifteen interviews with older patients provided support for four of seven key factors previously suggested by professionals as leading to underreferral of older adults: unclear referral pathway, complex differential diagnosis, gaps in referrer knowledge, and the length of time since onset. However, the patients interviewed did not report that patient difficulties accessing the hospital, patient reluctance to attend clinics, or the particular characteristics of older patients (knowledge, awareness, and willingness to ask for help) made it less likely that older adults would want to attend a specialist epilepsy clinic. While recognizing the limitations of the study, particularly in relation to the number of participants, we believe that it provides valuable further insights into the age-bias apparent in referral patterns to specialist epilepsy services. Of particular concern are professional assumptions regarding older patients' willingness to attend appointments and about the impact of seizures on the life of an older adult.     

Caring for mental illness in the United States: a focus on older adults.

OBJECTIVE: The authors compared rates of common mental disorders and the use of primary care and specialty mental health services among younger and older adults. METHODS: They used data from 9,585 respondents to the HealthCare for Communities (HCC) Household Telephone Survey. Mental disorders during the past year, including depression, dysthymia, and generalized anxiety disorder, were identified with a short questionnaire. The survey also collected information about sociodemographic and insurance status, perceived need for mental health care, and use of health services. RESULTS: Older adults (age 65 and older) were significantly less likely than younger adults (18-29) or middle-aged adults (30-64) to meet diagnostic criteria for a mental disorder (8% versus 15% in each of the younger age-groups). Older adults who met diagnostic criteria for mental disorders were less likely to perceive a need for mental health care, to receive specialty mental health care or counseling, or to receive referrals from primary care to mental health specialty care than young or middle-aged adults. CONCLUSION: Few older adults with mental disorders use mental health services, particularly specialty mental health services. The lack of perceived need for mental health care may contribute to low rates of mental health service use among older adults.     

Intrinsic and extrinsic barriers to mental health care among community-dwelling younger and older adults

This study examined intrinsic and extrinsic barriers to mental health care among younger (n = 76; M age = 23 years) and older adults (n = 88; M age = 71 years) using a new 56 item self-report measure, Barriers to Mental Health Services Scale (BMHSS). The BMHSS was developed to examine 10 barriers to the utilization of mental health services: help-seeking attitudes, stigma, knowledge and fear of psychotherapy, belief about inability to find a psychotherapist, belief that depressive symptoms are normal, insurance and payment concerns, ageism, concerns about psychotherapist's qualifications, physician referral, and transportation concerns. Results indicated that younger adults perceived fear of psychotherapy, belief about inability to find a psychotherapist, and insurance concerns to be greater barriers than older adults. Men perceived stigma to be a greater barrier than women whereas women perceived finding a psychotherapist to be a greater barrier than men. The rank order of the BMHSS subscales was strongly similar for younger and older adults (r = 0.90, p = 0.000). These results also provide further evidence that stigma about receiving mental health services is not a primary barrier among younger or older adults.     

A systematic review of the effectiveness of community-based mental health outreach services for older adults

OBJECTIVES: Psychiatric outreach services that provide mental health assessment and treatment to older adults in their homes or communities are widely promoted as improving access and outcomes for older adults. However, a systematic review of the efficacy of these services has not been done. This review evaluates the evidence base for the effectiveness of outreach services for older adults with mental illness in noninstitutional community settings. End points of interest include the ability of the outreach program to increase access to mental health services and improve psychiatric outcomes. METHODS: MEDLINE, CINAHL, PsycINFO, and Web-of-Science databases were searched for articles in English that were indexed through May 2004. Studies were included if they evaluated face-to-face psychiatric services provided to adults aged 65 and older with mental illness and if they were randomized controlled trials, quasi-experimental outcome studies, uncontrolled cohort studies, or comparisons of two or more interventions. Articles were excluded that evaluated interventions that were provided in institutional settings or that focused on persons with dementia or their caregivers. RESULTS: Fourteen studies matched all the inclusion criteria. Two studies (one controlled prospective study and one study that used a comparison group) found support for the use of gatekeepers-nontraditional referral sources-in identifying socially isolated older adults with mental illness. Twelve studies (five randomized controlled trials, one quasi-experimental study, and six uncontrolled cohort studies) found that home and community-based treatment of psychiatric symptoms were associated with improved or maintained psychiatric status. All randomized controlled trials reported improved depressive symptoms, and one reported improved overall psychiatric symptoms. CONCLUSIONS: Limited data supported the effectiveness of outreach services in identifying isolated older adults with mental illness. A more substantial evidence base indicated that home-based mental health treatment is effective in improving psychiatric symptoms. Studies are needed that apply more rigorous methods evaluating the efficacy of case identification models and subsequent treatment for older persons with a variety of psychiatric diagnoses.     

Factors related to potentially harmful behaviors towards disabled older people by family caregivers in Japan

OBJECTIVE: The purpose of the present study was to examine factors related to potentially harmful behaviors (PHB) by family caregivers towards their older family members. METHODS: Four hundred and twelve pairs of disabled older adults and their family caregivers participated in the study. All of these disabled older adults were users of visiting nursing services under the public Long-Term Care insurance system, who resided in one of the eight catchment areas of visiting nursing services in Kyoto Prefecture, Japan. The caregivers were asked to complete questionnaires in relation to their PHB towards their older family members, caregiver burden, patient-caregiver kinship, behavioral disturbances of their older adult, age and sex. Visiting nurses obtained the following information regarding the older adults: the severity of dementia; the severity of physical impairment; age and sex. RESULTS: More than 30% of the caregivers admitted PHB towards their older family members. The most frequently reported PHB included verbal aggression (16.8%) and ignoring (13.6%). A logistic regression analysis revealed that adult children (OR = 2.69, 95%CI = 1.23-5.89, p = 0.013) and caregivers of disabled older people with behavioral disturbances (OR = 3.61, 95%CI = 1.65-7.90, p < 0.01) were more likely to show PHB. CONCLUSIONS: In the present study, PHB towards the older people by family caregivers was associated with patients' behavioral disturbances and patient-caregiver kinship, i.e. an adult child as a caregiver. These findings should be taken into account when planning strategies to prevent PHB by family members.     

Locations of facilities with special programs for older substance abuse clients in the US

BACKGROUND: Given the growth of our aging population, developing strategies for managing late-life alcoholism is increasingly important. OBJECTIVE: We compared substance abuse treatment facilities with and without services designed for older adults and explored the location of these services relative to the regional distribution of older adults across the United States. METHODS: A public use dataset from a national survey of facilities offering substance abuse treatment was used to address this issue. This survey included all identified substance abuse/dependence treatment facilities in the US and surveyed the facilities' treatment services, services for special groups, number of clients admitted, type of ownership (e.g. public, private for profit), and whether or not the facility was associated with a hospital, as well as questions about licensure and income sources. RESULTS: Of the 13 749 responding facilities, relatively few programs (17.7%) were specifically designed for older adults (i.e. over age 65). Facilities with such programs tended to be associated with hospitals, particularly those with a psychiatric inpatient service. Importantly, the number of facilities with special programs for older adults did not correlate with size of the older population in each state. CONCLUSION: Despite an increasing need for older adult substance abuse services, there are relatively few programs available designed for this age group. The setting where patients with substance abuse are identified (e.g. in a hospital) may partially explain the pattern of locations of age-specific programs.     

Unmet Needs for Mental Health Services for Latino Older Adults: Perspectives from Consumers, Family Members, Advocates, and Service Providers

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.     

Recent research on suicide in the elderly

Older adults, and older men in particular, are the segment of the US population that has the highest suicide rate. Although research on risk factors continues to grow, there remains limited knowledge of the biologic changes that increase risk for suicide, as well as limited information about contributing psychosocial processes that extend beyond demographic factors. No proven interventions are known at this time, although efforts are underway to test approaches that reach older adults who use primary care services. Continued efforts are needed to change attitudes about mental illness and treatment in order to reach older adults who do not use health care services.     

Engaging an Asian Immigrant Older Adult in Depression Care: Collaborative Care,Patient-Provider Communication and Ethnic Identity

Minority older adults face multiple barriers when trying to access mental health services and often present with more severe symptoms of mental health conditions. We describe the multilevel factors that contributed to the engagement of an Asian immigrant older adult with depression. Systems-level innovations such as collaborative care in primary care can increase access to care for all, including minority older adults; however, one size fits all interventions may not meet the needs of communities of older adults with different life experiences, language needs, norms and values regarding help-seeking for mental health. Health outcomes remain unequal , suggesting the need to tailor interventions for minority older adults. For the patient, specific factors related to language and ethnic concordance between patient and healthcare provider, communication behaviors, ethnic identity, and social norms may be important to take into account. The recognition of the heterogeneity of patients and the limitations of cultural competence approaches defined as broad, general knowledge about ethnic cultures may be needed. A need to learn continuously from clinical experience and adopt a patient-oriented model of communication and decision-making may successfully engage Asian immigrant older adults in depression care services.     

Specialized partial hospitalization for older adults: a clinical description of an intermediate-term program

The field of geriatric mental health is confronted with the dilemma of a sharp rise in the elderly segment of the population and a concomitant shortage of age-appropriate psychiatric intervention services. There is tremendous need for specialized hospital-based intervention for older adults with mental health problems. A creative and rapid response is imperative and should be based on a continuum of geropsychiatric services that includes acute inpatient, partial hospitalization, and outpatient services. Because Medicare reimbursement for partial hospitalization is restricted to hospital-based programs, private psychiatric hospitals are uniquely positioned to assume a dominant role in the geriatric mental health service delivery system. This article details one hospital's specialized, intermediate-term partial-hospital program for older adults. Partial hospitalization is demonstrated to be an essential component of comprehensive geropsychiatric services that can overcome problems of cost-effectiveness, accessibility, and acceptability to consumers--all factors that presently restrict the development and use of such programs. Based on empirical findings, clinical adaptations to assessment and treatment procedures specific to older adults are presented.     

Public's view of mental health services for the elderly: responses to Dear Abby

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.     

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups.

OBJECTIVE: The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery. METHODS: Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates). RESULTS: The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services. CONCLUSION: Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.     

Public Mental Health Care Utilization by Older Adults

The present study examined the extent to which older adults began public mental health treatment throughout Texas in 1999, the types of services they used, and how they compared on demographic and clinical variables to younger consumers. Notwithstanding recent policy and related developments, older adults were found to use public mental health services at substantially low rates, as in past decades. Significantly, older consumers tended to be relatively healthy and independent. Among younger and, even more so, older consumers, there were relatively high proportions of rural residents and minorities, groups previously found to be unlikely to utilize private mental health services. Overall, the findings urge that greater attention be devoted to public mental health outreach and service delivery with the elderly, and raise the question of what role the public mental health system should have in nursing homes and other long-term care settings.     

Are the Health of the nation outcome scales (HoNOS) useful for measuring outcomes in older people'smental health services?

The Health of the Nation Outcome Scales (HoNOS) were developed to provide a single index in order to enable the government target 'to improve significantly the health and social functioning of mentally ill people' to be quantified. They were intended to be applicable to all adults (including older people), across a wide range of settings so that services in different localities could be compared and changes both within individuals and within services could be measured. In 1999 the HoNOS65+ was launched with a modified glossary for older people. The HoNOS has been formally adopted as the preferred outcome measure for adults of working age. There has been no such formal adoption of the HoNOS65+, or any other outcome measure, for mental health services for older people. This review summarises how the HoNOS was originally developed and validated. Studies with older people, which have used both the original definitions and those developed for the HoNOS65+ are reviewed focusing on data on the reliability and validity of the HoNOS and HoNOS65+ with older people. Finally the question of whether the HoNOS or HoNOS65+ is suitable as an outcome measure in routine clinical practice in services for older people is addressed.