Mental Illness: The Issue

Over 20% of adults over age 65 have a mental disorder (Jeste, Alexopoulos, Bartels, Cummings, Gallo & Gottlieb, 1999). Most of this population is cared for in the community, primarily by informal caregivers.

Older adults with mental illness are a unique population. On the one hand, older adults experience age-related physical, psychological and social changes that individually and together may challenge their mental health. For some, this may result in the development of a mental illness for the first time in late life. For others who have a lifelong mental illness, age-related changes may present new challenges.

The range of mental illnesses suffered by older adults is varied. Prevalence rates for specific mental disorders in community dwelling older adult populations are as follows: 5.5% for anxiety disorders; 6.3 % for paranoid ideation ; .1% for schizophrenia and 5.9 % for personality disorder (Zarit & Zarit, 1998) . The prevalence rate for major depression in the general community population of seniors is 3.5%,, but where medical illness occurs the rate is 20-30%. (Conn, Herrmann, Kaye, Rewilak & Schogt, (2001). Based on their review of the research literature, Gallo and Lebowitz (1999) estimate that up to 15 to 20 % of older adults have significant depressive symptoms, with the figure rising to as high as 45 % in adults aged 85 years and older.

Depressive symptoms in the elderly are associated with an increased risk of functional decline and cognitive impairment. Suicidality is linked with major depression. Older adults make fewer suicide attempts than younger adults but their attempts are more likely to result in death (Pearson and Conwell, 1995; NAMI, 1991). A British Columbia study revealed that elderly people accounted for 14 % of the total deaths in B.C. by suicide (White & Rouse, 1997). The researchers identified failing health and loss of a loved one (common occurrences in late life) as the leading predictors of older persons’ suicide. It was also noted that over one third of victims had a known psychiatric disorder, primarily depression, but few were in receipt of mental health services.

This study confirms the seriousness of mental illness for elderly British Columbians, and raises questions about the accessibility and appropriateness of services for them. Alcohol misuse is a concern for many older adults, and there is substantial comorbid substance use by mentally ill seniors (Evans, 2000; Raue, et al., 2001). Although alcohol misuse in the elderly is believed to be hidden and underreported, one study of seniors living in the community revealed that 62 % of the individuals consumed alcohol, with heavy drinking being reported in 13 % of men and 2 % of women (Rigler, 2000). Approximately one third of older adults who misuse alcohol may have acquired a drinking problem in late life (British Columbia, Ministry of Health, 2002).

It is estimated that only one third of community dwelling seniors suffering from a mental illness are able to access the mental health services they need and that up to 63 % have unmet needs for mental health services (Bartels and Smyer, 2002). Arksey (2003) reports that despite a tremendous need for services by the chronically mentally ill older adults, they tend to receive little more support than symptom management. There is evidence to indicate that depression (Brown, Bruce, Pearson and the PROSPECT Study Group, 2001; Banerjee (1998), substance abuse (Fischer, Wei, Solberg, Rush and Heinrich, 2003) and suicidality (Préville, Boyer, Hébert, Bravo& Seguin M. 2005) are poorly managed in the community.

According to a Senate Committee review of the mental health system in Canada, specialized mental health programs and services for mentally ill older adults without dementia are lacking and inadequate (Kirby & Keon, 2004). Older adults in British Columbia, particularly in rural communities, have limited access to geriatric mental health specialists and supportive services (e.g., day programs, housing) (McGee, Tuokko, MacCourt and Donnelly, 2005). Most services are provided through generic mental health programs or generic programs for older adults. On the one hand, mental health services designed for younger adults frequently focus on education, employment and other life tasks that may be less relevant to elderly people, and that assume a younger person’s life stage.

As well, where older adults develop age-related physical and /or cognitive deficits they may no longer be able to access services designed for younger people. In regard to generic services for seniors, they tend to target either dementia or physical frailty and may not meet the needs of elderly people with other mental illnesses or the needs of their caregivers. Issues and challenges relevant to the presentation and management of both seniors with dementia and of younger mentally ill adults are likely to be very different than those for older adults with mental illnesses. This implies that the needs of caregivers of older adults with mental illnesses, and how to meet them, may also differ from those of other caregivers.


Resources

The Canadian Coalition for Seniors Mental Health (CCSMH) has led the development of National Guidelines for Seniors Mental Health

The Assessment and Treatment of Delirium

Assessment of Suicide Risk and Suicide Prevention

The Assessment and Treatment of Depression

The Assessment and Treatment of Mental Health Issues in Long Term Care Homes (With a Focus on Mood and Behaviour Symptoms)

References

Arksey, H. (2003). Scoping the field: services for carers of people with mental health problems. Health and Social Care in the Community, 11(4), 335-344.

Bartels, S.J., Smyer, M.A. (2002). Mental disorders of aging: an emerging public health crisis? Generations,
Spring 2002, 14-20.

British Columbia Ministry of Health (2002). Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities: British Columbia Health Services

Brown, G., Bruce, M., Pearson, J., and PROSPECT study Group (2001). High-risk management guidelines for elderly suicidal patients in primary care settings. International Journal of Geriatric Psychiatry, 16: 593-601.

Conn, D., Herrmann, N., Kaye, A., Rewilak, D. & Schogt, B. (Eds.) (2001). Practical psychiatry in the long-term care facility. Hogrefe & Huber Publishers, Seattle.

Evans, D. L. (2000). Bipolar disorder: Diagnostic challenges & treatment considerations. Journal of Clinical Psychiatry, 61(Supp. 13), 26-31.

Fischer, L., Wei, F., Solberg, L., Rush, W. & Heinrich, R. (2003). Treatment of elderly and other older adult patients for depression in primary care. JAGS 51:1554-1562.

Gallo, J.J., Lebowitz, B.D. (1999). The epidemiology of common late-life mental disorders in the community: themes for the new century. Psychiatric Services, 50(9), 1158-1166.

Jeste, D., Alexopoulos, G., Bartels, S., Cummings, J., Gallo, J. Gottlieb, J., et al (1999). Consensus statement on the upcoming crisis in geriatric mental health research agenda for the nest two decade. Archives of General Psychiatry, 56: 848-53.

Kirby, M. J. L. & Keon, J. (2004). Canada, Parliament, Senate Standing Committee on Social Affairs, Science and Technology. Report 3: Mental health, mental illness and addiction issues and options for Canada. Ottawa, ON, Canada

NAMI. Depression in Older Persons [Electronic Version] from www.nami.org. National Institute of Mental Health (1991). Elderly mentally ill served by NIMH-funded projects in 16 states – National Institute of Mental Health. Aging (Winter).

Pearson, J., Conwell, Y. (1995). Suicide in late life. International Psychogeriatrics, 7, 131-136.

Préville M, Boyer R, Hébert R, Bravo G, Seguin M. (2005). Correlates of suicide in the older adult population in Quebec. Suicide and life threatening behaviour, 35(1): 91-105.

Raue, P.J., Alexopoulos, G.S., Bruce, M.L., Klimstra, S., Mulsant, B.H., Gallo, J.J. (2001). The systematic assessment of depressed elderly primary care patients. International Journal of Geriatric Psychiatry, 16, 560-569.

Rigler, S. (2000). Alcoholism in the elderly. American Family Physician, 61(6).

Tuokko, H., MacCourt, P., Donnelly, M. (2001). Meeting the mental health needs of older British Columbians. Report

White, J., Rouse, D. (1997). Data report on the psychosocial characteristics of completed suicides in British Columbia: B.C. Suicide Prevention Program Report

Zarit, S. & Zarit, J. (1998) Mental disorders in older adults. Guilford Press: New York.