Discrimination is at the heart of many of the problems in mental health services for older people. The independent UK Inquiry into Mental Health and Well-Being in Later Life found that discrimination – both by age and condition – drives and maintains many of the poor services facing older people with mental health problems.
The ‘mental health pandemic’ means that over 3.5 million older people experience mental health problems and many do not have satisfactory services and support. The Inquiry report reveals that mental health problems affect many more people in later life than previously believed. It shows that up to 2.6 million older people – a quarter of people over 65 – have signs and symptoms of depression which need an intervention. A fifth of people over 80 have dementia.
Furthermore, people growing older with longstanding mental health problems, such as schizophrenia, are almost invisible in our systems and can be required to move out of services just because of their age. And people who develop mental health problems in later life are often ignored and receive little support.
The cause of many of these difficulties is embedded discrimination in both systems and attitudes. It is this discrimination that means a doctor can tell an older person that depression is a symptom of getting older, that innovative projects like Talking Therapies have been set up to exclude older people and that people can be asked to move out of the mental health day care services they have used over many years when they hit their 65th birthday.
The primary form of discrimination is on the basis of age. It affects decisions and services from strategic decisions to the way individual older people are treated by their doctor or care worker.
No one is able to offer a reasoned or logical argument for the separation of the planning and provision of mental health services on the basis of chronological age. The presumed driver behind this separation – the incidence of dementia amongst older people – shows the careless generalisation that drives this discrimination.
Although the incidence of dementia increases with age, there are more older people with depression than with dementia and more people are growing older with longstanding mental health problems such as schizophrenia. There are also many people under 65 who develop dementia including, but not only, people with learning difficulties. At every level these so-called exceptions fit uneasily within the structure of services and often do not receive the care and support they need.
Those with depression miss out on a great deal due to age discrimination. At the heart of this discrimination is the fallacy that depression is an inevitable part of getting old. It is only part of getting old in the UK because of failures within our public policy for older people and mental health – and the gap between the two into which older people often fall.
Social exclusion, low incomes and a lack of appropriate opportunities to engage in the life of the local community all contribute to depression. There are 2.2 million older households in sub-standard housing and there are 1.8 million older people in poverty or just above the breadline.
The services also aren’t in place to help older people. Across the land, we have heard of GP after GP, health professional after health professional, dismissing people with symptoms of depression.
At best, an older person with depression may be offered anti-depressants – even when what they really need is the opportunity to talk through the problems they are facing and come up with some practical solutions. Prozac Nation was about the wrong age group. This is not just practitioners either. Policy initiatives from psychological therapies, suicide reduction and tackling alcohol and drug misuse, are all developed as if they have no relevance to older people.
People with longstanding mental health problems often face similar problems as they grow older. They may have lived with their condition, such as schizophrenia or bi-polar disorder, their entire adult life, but once they reach 65 many receive different and inferior services. The money spent on their services will be much less and they often stop receiving services that encourage independence. They focus on encouraging stability and minimising costs instead. In essence, they often find themselves in services designed for people with dementia. People with depression also report the same problem.
Attempts to overcome this age discrimination have often been handled with little thought or understanding. In some places, sometimes in organisations which are also looking for cost savings, there has been an immediate move from direct discrimination to indirect discrimination, with the assumption that no specialist older peoples’ mental health services are needed.
This Inquiry calls for age equality in mental health, where individual need rather than chronological age determines access to services. We are clear that there is and will remain a need for specialists in the mental health needs of older people, particularly for people with complex needs, but terms such as ‘old age psychiatry’ are not helpful in clarifying the skills and knowledge on offer. We are equally clear however that the majority of older people with mental health needs will not need specialist services but that there is an enormous gap to be filled in the training of all health and social care professionals to equip them to recognise and respond to mental health needs amongst older people.
While the picture is bleak, there are some causes for optimism. Many of the mental health problems facing older people can be prevented and for those which cannot be prevented, people can be helped to maintain an active and productive role in our society. More resources are clearly needed but changes to attitudes and imaginative use of existing resources are equally important. The Department of Health has acknowledged that age discrimination remains in mental health services and needs to be tackled. This acknowledgement is a step in the right direction, and we welcome the commitment of Professor Ian Philp, National Director for Older People, to push for change.
eport makes 35 recommendations. The first is calling for the establishment of a Government Task Force to drive the improvement in mental health services for older people.
We identify a relatively simple policy step that can really make a difference to mental health service: the inclusion of a positive public duty on age discrimination in the Single Equality Act. This will mean that the differences between the services received by older people and younger people will stop. But we must be careful that this is not used as an opportunity to cut services for people under 65, but to increase services for older people.
This should be extended so that the principle of age equality is incorporated into all mental health policies, performance indicators, strategies and initiatives across Government, and ensure that older people’s specific needs are identified and addressed. Government should lead by example and eliminate the inconsistencies that exist across departments. One measure of success would be the elimination of policies defined by chronological age.
The Commission for Equality and Human Rights also must demonstrate real leadership. We are calling for the Commission to conduct an inquiry in 2008 into equality and human rights in mental health services, with a focus on age equality. Such an inquiry would provide an opportunity to explore the multiple and overlapping forms of discrimination experienced by older people with mental health problems.
And we need to be honest about the fact that our education and training systems have failed to equip workers with the skills and knowledge they need to identify mental health needs and respond appropriately. All education providers, regulators and employers need to act to rectify this situation.
A key test for commissioners and joint working between local authorities and the NHS will be the extent to which they are able to work together to plan and deliver services and support for older people which both prevent mental health problems and provide support to those who are living – and dying – with a mental health need.
Ageist practices that discriminate against people over 65 with mental health needs are too often accepted by policy makers and service providers. All the signs show not enough has been done, and rather than just policy commitments we need to see action. We hope our report will really kick start debate, and ensure that older people with mental health problems get the help they need. – Over 3.5 million older people who currently experience mental health problems do not have satisfactory services and support – By 2021, there will be 3.5 million older people with symptoms of depression and nearly 1 million with dementia – By 2051, there could be 5 million older people with depression and 1.7 million with dementia – The unmet mental health needs of older people will cost £245bn per year from lost consumers, £230bn in lost workers, £15bn from the absence of older carers, £5bn from lost volunteers, £4bn from lost grandparents by 2021 Source: UK Inquiry into Mental Health and Well-Being in Later Life
Full inquiry report
For more on ageism
Gordon Lishman is director general, Age Concern
– Over 3.5 million older people who currently experience mental health problems do not have satisfactory services and support
– By 2021, there will be 3.5 million older people with symptoms of depression and nearly 1 million with dementia
– By 2051, there could be 5 million older people with depression and 1.7 million with dementia
– The unmet mental health needs of older people will cost £245bn per year from lost consumers, £230bn in lost workers, £15bn from the absence of older carers, £5bn from lost volunteers, £4bn from lost grandparents by 2021
Source: UK Inquiry into Mental Health and Well-Being in Later Life