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G E N E R AT IO N S – Journal of the American Society on Aging

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Mental health care for older adults lags behind that for other age groups, in both the developed and developing world. Helping older adults and healthcare providers identify potential mental health problems is an impor- tant first step toward ensuring better care. In the coming decade, we must turn clinical and research attention to cohorts such as the oldest- old and those of culturally and linguistically diverse backgrounds. Varying national and cultural systems are reflected in how nations organize and deliver healthcare services, including mental health care, but all are under increasing pressure because of the growing numbers of frail older adults and of those with dementia. The need also is accelerating for age-literate mental health care workers. In many regions of the world, there are policy issues and directives that pertain to older populations’ mental health, while in many other areas such initiatives are still evolving.

This article describes issues confronting older people—as well as the healthcare systems that serve them—in developed and developing nations. It highlights recent research and reviews to point

out critical issues affecting older adults globally, and presents challenges and future directions for research and clinical practice.

Identifying Mental Health Problems in Older Populations The aging of the population has focused atten- tion on the mental health of older adults, from the perspectives of clinical practice, research inquiry, service delivery, and government policy. But first, how can we identify those in the com-

munity in need of mental health services? Traditionally, mental health diagnostic

systems have not been particularly concerned with how symptoms present in later life. This has changed recently with revisions, both suggested and anticipated, to the Diagnostic and Statistical Manual of Mental Disorders (DSM), as well as to the World Health Organization’s International Classification of Diseases. Recent

By Nancy A. Pachana

A Global Snapshot of Mental Health Issues, Services, and Policy

Changing global demographics have prompted new thinking about policy concerning mental health priorities in later life.

‘Traditionally, diagnostic systems have not been particularly concerned with how mental health symptoms present in later life.’

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discussions around proposed DSM5 (fifth edition) changes have highlighted issues with respect to diagnosing older adults of culturally diverse backgrounds. One goal of the DSM’s current revision is to ensure culturally appro- priate approaches to those with mental health issues (American Psychiatric Association, 2011), which is crucial given increasing global migra- tion within all age groups.

Cultural diversity raises particular issues for older adults. Rose and Cheung (2012) have done a qualitative analysis of published studies on assessing mental health in such populations with respect to proposed DSM5 changes. They highlighted five issues: degrees and processes of acculturation; unique cultural experiences with respect to mental health issues; health dispari- ties among various cultural groups within a given society; evidence-based dementia practice; and, diverse prevalence of anxiety and depres- sion across cultural groups. As DSM criteria are used in a variety of settings, the authors con- clude that competence in assessing mental health problems across diverse populations is growing in importance and deserves careful consideration in the diagnostic process.

Part of the difficulty in assessing mental health concerns between both diverse cultural groups and within the majority culture, is the idea that mental health problems are to be expected later in life. Anxiety and depression prevalence rates have been published in numer- ous countries for diverse groups, and yet a stereo- type of depression and anxiety being “normal” in later life remains. For example, the U.S. Centers for Disease Control (2008) noted that contrary to popular belief, older adults older than age 65 do not report experiencing frequent mental

distress, and lifetime histories of depression and anxiety are low (10.5 percent and 7.6 percent, respectively). These percentages are lower than those reported for adults ages 50 to 64 years (19.3 percent and 12.7 percent, respectively).

Despite research on older adults’ interper- sonal and psychosocial resources, this ageist myth persists among both healthcare profession- als and older adults (Whitbourne, 2001). More

recently, Bryant and colleagues (2012) examined attitudes among older adults toward aging and the impact of such attitudes on quality of life. Adults older than age 60 (N=421) were asked to complete questionnaires rating their attitudes toward aging and various

quality-of-life issues and self-reporting mental health problems. More positive attitudes toward aging in this group were associated with a higher level of satisfaction with life, better self-reported physical and mental health, and lower levels of self-reported anxiety and depression. This shows ageist attitudes are of concern, not only in identifying mental health problems, but also as an important risk factor in their development in later life.

Subgroups of Particular Interest Approximately 36 million people worldwide live with dementia, and these numbers are set to double every twenty years to approximately 115 million by 2050 (Alzheimer’s Disease Interna- tional, 2011). Most dementia care is provided for patients in their homes, and providing such care takes a toll in terms of health, social, economic, and emotional costs (World Health Organization [WHO], 2012). In its 2012 report on dementia, the WHO strongly urges nations to structure dementia care policies that balance searching for a cure with providing quality evidence-based care for those currently affected.

In light of this directive, the recent meta- analysis of high-quality dementia caregiver interventions by Brodaty and Arasaratnam (2012) offers good news. In this analysis,

Many psychotherapists working with older people may be confronted with their own unacknowledged fears about increased disability, aging, and mortality.

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twenty-three such studies were examined, involving 3,279 family caregivers of community- dwelling persons with dementia. There were demonstrated reductions in behavioral symp- toms and negative caregiver reactions from the interventions. These improvements, although modest, compare favorably to trials using drug-based treatments. The most successful interventions were tailored to specific behav- iors, needs, and contexts of the care situation. Improvements in both behaviors and caregiver well-being can help those with dementia live at home longer, with few or no adverse side effects, compared to drug treatments. In light of recent published concerns about the use of anti-psychotics in older persons with dementia (Steinberg and Lyketsos, 2012), this study pro- vides powerful evidence that such psychosocial interventions should be central to managing behavioral symptoms in dementia.

Another subgroup of the global aging pop- ulation receiving increased attention is that of the oldest-old (ages 85 years and older). Globally, the fastest growth in population is seen in this age group, with projections for a nearly fivefold increase in this group by 2050, from 88 million in 2005 to 402 million (United Nations Depart- ment of Economic and Social Affairs [UN DESA], 2007). Importantly, 80 percent of older people will live in low- and middle-income countries, with an increasing proportion of these also comprising frailer older adults of more advanced ages (UN DESA, 2010). Although we may make distinctions and assumptions about adults who fall into young–old and old–old categories, older adults are a heterogeneous group and likely to become even more so as longevity increases. This is an important point to carry into clinical work with older adults: while chronological age may provide some limited orienting information about general expectations, at an individual level, the older person’s unique context and perspective are all-important, making age perhaps the least important clinical variable (Laidlaw and Pachana, 2009).

Perhaps most important is that healthcare providers have a good working knowledge about normal aging from young−old to old−old popula- tions, despite research still tending to focus on relatively younger cohorts in the latter half of life (Laidlaw and Pachana, 2009). Older adults express preferences for various treatments for mental health concerns at different ages, be they pharmacological or non-pharmacological, and their voices need to be heard. Mohlman (2011) found in a survey of community-dwelling participants (N=383) a self-reported preference among young–old adults (ages 65 to 74) for cognitive-behavioral therapy for anxiety-related disorders, while the oldest–old group was more likely to prefer supportive therapy. Finally, with increasing proportions of older adults of ad- vanced age seeking treatment, many psychother- apists working with older people may be con- fronted with their own unacknowledged fears about increased disability, aging, and mortality. What may have been an abstract concept of morbidity and frailty may now become discom- fortingly real (Koder and Helmes, 2008).

Training and Workforce Issues This notion of mental health workers across disciplines needing to confront ideas of ageism, bias, discomfort, and anxiety points to the need for more training in working with older adults. Such calls for additional training have spanned disciplines (e.g., psychiatry; Jeste et al., 1999) and regions of the world (for example, Portugal responded to its aging population with innovative multi-disciplinary healthcare training initiatives; Ribeiro et al., 2010). Improving training in mental health care for older adults requires attracting students into this sub-discipline, ensuring curri- cula match the needs of older adults, and pro- viding high-quality placement experiences for students, with adequate supervision.

Unfortunately, such training lags. A study by Pachana and colleagues (2010) compared issues of staffing, pedagogical content, and placement opportunities across clinical psychology training

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programs in the United States, Canada, and Australia. Across countries the more salient findings included the intertwined issues of a need for academic staff with geriatric expertise and training programs focusing on diagnosis and assessment, with relatively little attention paid to interventions. Such studies offer a way to argue for curriculum and staffing changes within clinical training programs.

The WHO (Global Agenda Council on Aging Society [GACAS], 2012) has highlighted the broader issue of adequately preparing healthcare providers to serve the needs of an aging popula- tion. The report stressed a need for medical school students to gain greater exposure to geriatric medicine, particularly in the care of those older than age 85 who have complex medical problems. Curricula must note the need for more geriatric- literate healthcare workers. Recently, the Association of Geriatrics and Gerontology and the WHO have put forth core competencies that should be addressed in medical training, irrespective of final specialization area (Mateos- Nozal and Beard, 2008). Meeting such compe- tency objectives in training will help assure quality patient outcomes in the future.

The Organization of Healthcare Services The way in which healthcare services are orga- nized reflects a country’s history of providing health services, funding schemes, cultural priorities, and economic realities. These differ in the developed and developing world, although in all countries increasing proportions of geriatric patients are causing strain in healthcare delivery systems, albeit to varying degrees. Globally, mental health care systems are tied to these same drivers and are also particularly sensitive to cul- tural norms and economic development levels.

Healthcare organization and policy will differ between countries with varying degrees of development and economic resources. Chal- lenges and opportunities differ here. Health- care systems and priorities in wealthier, more

developed countries were formed in an era where acute illnesses and younger patients were the focus of their societies. Now these systems must retool (and their managers must rethink) healthcare service delivery in light of changing demographics and priorities. Prevention, including primary, secondary, and tertiary prevention of diseases or conditions common in later life, must become prominent (GACAS, 2012). New models of cost-effective and innova- tive care systems should be tried, such as the geriatric-specific emergency room care in increasingly widespread use in the United States (Hwang and Morrison, 2007).

In less developed and more economically challenged regions of the world, a serious prob- lem is that aging populations will present with more costly non-communicable diseases, seeking treatment at healthcare centers often lacking in infrastructure and geriatric specialists (GACAS, 2012). In the developing world, healthcare com- petes with other priorities (education, food, and security). And rapid development has altered traditional family- and community-based care systems for older adults in these societies. A more proactive stance is required; suggested priorities would include emphasizing prevention and non- communicable diseases; encouraging healthcare workers to move to rural areas and supporting training for these workers; adapting technology to suit local realities; targeting the poor and under- served; and developing a primary healthcare sector (GACAS, 2012).

The WHO (2011) has developed and evalu- ated a toolkit based on age-friendly primary healthcare centers, offering a model for both developed and developing countries to orient them more toward meeting the needs of older adults. (The toolkit is freely available and can be

One international trend is to consider using interdisciplinary care systems for both health and mental health care services.

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downloaded at www.who.int/ageing/publica tions/upcoming_publications/en/index.html.)

Policy Issues and Initiatives: A Global Snapshot Across the globe, changing demographics have prompted rethinking policy with respect to mental health priorities in later life. One major trend is thinking more seriously about having inter-disciplinary care systems in place for providing both health and mental health care services. Such systems have good empirical support with respect to efficacy and outcomes efficiency (Heinemann and Zeiss, 2002). Basi- cally, in less hierarchically organized systems, care for older adults, particularly those with multiple comorbidities, can be less fragmented, and can be more sensitive to varying life experi- ences and contexts. The American Psycholo- gical Association (2008) offered a blueprint for achieving integrative healthcare solutions for older populations. An integrated healthcare model is characterized by a high degree of collaboration between various health profession- als serving patients at all stages of care, including assessment, treatment planning and implemen- tation, and evaluation of outcomes. It is more collaborative than hierarchical in its organiza- tion and has a strong capacity to flexibly meet challenges of diverse presentations and circum- stances. This model is appropriate across a variety of settings (primary care, residential care) and could be adopted in both developed and developing nations as an aspirational model for excellence in geriatric care.

In Australia, where models and policies regarding health and mental health care for

older adults across settings have been develop- ing over the last decade, a new initiative is worth noting. The Australian government recently announced the development of a Lesbian Gay Bisexual Transgender Intersex (LGBTI) Ageing and Aged Care Strategy to ensure the needs of these groups are met. Historically, LGBTI persons have faced stigma and discrimination in accessing and using aged care services. Various recommendations of the Australian National LGBT Health Alliance (2010) included funding national training for aged care workers on LGBTI issues for older adults, and an LGBTI aging strategic plan to ensure the aging services sector could be sensitive to and supportive of older LGBTI people’s needs.

Conclusion Global population aging has brought with it significant challenges and increased research into the mental health care needs of older adults. We are starting to see innovative solutions in ascertaining needs, developing and implement- ing interventions, and supporting an age-literate mental health care workforce. Research support- ing efficacious and efficient organization of mental health care services is increasingly informing policy initiatives in both the devel- oped and developing world. Ensuring that marginalized and under-studied populations are included in these efforts is a key challenge in the coming decade.

Nancy A. Pachana, a clinical psychologist and neuro- psychologist, is a professor in the School of Psychology at University of Queensland, Australia, and is co-direc- tor of the University’s Ageing Mind Initiative.

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