Tackling depression and improving mental health in older people
For anyone with depression the future can seem fearful. Depression makes disability worse, recovery from illness or treatment harder and reduces quality of life for older people. For those who work to support older people with depression these feelings might be shared. And we know that depression is commonly experienced by informal carers, making their tasks harder and less rewarding.
If we can successfully tackle depression the gains are likely to be considerable. As a public health issue there can be few areas where so many people’s lives might be improved, or at least their unhappiness decreased. The forthcoming inquiry report on mental health in later life by Age Concern England and the Mental Health Foundation will set out in detail some of the ways in which such gains can be achieved and will provide evidence for what works. If this report is taken seriously – by politicians, policy-makers, service providers, professionals and older people’s groups – this will be one sign that mental health in later life is being awarded at last the importance it deserves.
Placing depression in the public health zone is a challenge. It is a stigmatising condition, with secrecy and isolation affecting people’s actions and reactions. Who wants to admit that life seems hopeless? Who wants to say hat their work seems unrewarding, or that their services (care home, day centre, hospital ward) contain many people with a depression that is untreated and often ignored?
Tackling depression requires us to think about vulnerabilities and risks but for the future we need to ask more about resilience and protective factors. Why are some people not depressed? What keeps them well? How can we enhance this?
We need also to focus on people who already have depression and work with them to give then the long-term support that might be awarded to other physical conditions. Can the annual health checks for people with severe mental illness by primary care services make a difference here?
We need to recognise the stress and strain on carers, both informal and those working with older people who are sick, disabled or dying. Much is said of workforce shortages but often there is little care of existing staff. Improving their mental health should also be a priority so they do not remain the casualties of the system.
We now know that psychosocial treatment, sometimes combined with medication, works well for some older people with depression. But the challenge lies in the resources for this: where is the budget increase, where is the training and workforce strategy to deliver ‘talking cures’ and how will good practice be spread widely? Much may depend on the willingness of older people themselves to put these questions to health and public services, not just social care. In this they might usefully joint with those campaigning to improve dementia care, for here the campaigning and advocacy roles are slowly bearing fruit, and the links between dementia and depression are becoming evident.
Similarly we need to pay more attention to those older people whose mental health problems pre-date old age. Most attention is given to those people who develop dementia and depression in later life, forgetting sometimes that some people have lived with mental health problems for much of their adult lives. They are often neglected and yet are likely to be growing in number. They are the people who are facing possible gaps betweens services as they become too old for ‘adult’ services and yet find themselves much younger than most people in ‘older people’s’ services’. For some their problems are complex and they may have addiction problems, be homeless or socially excluded in many ways. Their problems require flexible services, wrapped around them, and yet with the time to build relationships and trust. Improving their mental health is also likely to link to efforts to raise their physical well-being since many will be experiencing disability and ill health.
In the future the many facets of mental health in later life will need to be explored, apart from the major issues of depression and dementia. How will we respond to the mental health needs of older prisoners? How will we respond to the emerging needs of refugees as they age? We have much good practice to build on but also a history of neglect and a reliance on safety nets that may be wearing thin.
To conclude by returning to depression, since this is a common thread behind many of the problems discussed above: past documents like this have often urged professionals and the public to ‘recognise’ depression. This is not the main task for the future. The challenge now is to develop systems of responses, to monitor their effectiveness and to see depression as a public health issue as well as a personal sorrow.
Social Care Workforce Research Unit
King’s College London