Elderly people with depression let down by the system

Depression among older people often goes untreated, but social care holds the key to keep it at bay, writes Mark Hunter

When Age Concern released a report last month revealing that two million people in England over the age of 65 were suffering from depression, it hardly came as a surprise. Indeed, the link between old age and depression is so well established that it has become a self-fulfilling prophesy. Older people are almost expected to be depressed, so when they begin to exhibit symptoms of depression, it is considered to be just a normal part of ageing and nothing is done.

According to the Age Concern report only about 15% of all older people with clinical depression receive any treatment at all and only 6% receive specialist mental health care. This compares with about 50% of younger adults with mental and anxiety disorders.

In part, the low referral rate for elderly people is because many depressed older people simply do not seek help for their problems. “Negative attitudes about mental health problems make it very difficult for older people to talk about their feelings or to ask for help,” says Age Concern’s director general Gordon Lishman.

Friends, family and even care home staff may not recognise the symptoms. In one study of nursing and residential homes, staff were able to recognise only 15% of residents with depression. Less than 2% of the staff had received training on the condition.

“Care home staff and managers must ensure their own knowledge of symptoms associated with depression is improved,” says Elizabeth McLennan, senior policy officer at Help the Aged. “It is all too easy for older care home residents who are suffering depression to be without the right levels of support and treatment.”

But even when older people with depression do seek medical help they are often let down by the system. Age Concern claims that as many as half of older people in care homes who are diagnosed with depression do not receive treatment. This raises the question of who diagnosed the condition and, if it was a doctor, why they decided not to treat it.

But it is not only these ageist attitudes and preconceived ideas that are standing in the way of effective management of depression in the elderly. They also face a deep-rooted and discriminatory division in the way that mental health services are organised.

In most local authorities and NHS trusts mental health services are structured separately for adults of working age (under 65) and older people (over 65). Often, a service that is provided on one side of the age divide is not provided on the other. For instance, psychological services, crisis resolution and home treatment services, assertive outreach and intermediate care services are often only available to those under 65. This can be especially upsetting for those who are required to transfer from one system to another simply because they have passed their 65th birthday. Suddenly a service that has been provided for many years may be taken away or replaced by something that is completely unfamiliar.

In 2006 three national commissions (Healthcare, Social Care Inspection and Audit) joined forces to conduct a review of the National Service Framework for Older People. They found that explicit age discrimination within the NHS and social services had declined significantly since the framework had been in operation. With one marked exception: mental health.

“The organisational division between mental health services for adults of working age and older people has resulted in the development of an unfair system, as the range of services available differs for each of these groups,” says the report. “Older people who have made the transition between these services when they reached 65 have said there were noticeable differences in the quality and range of services available.”

As if explicit age discrimination wasn’t bad enough, older people with depression face one further obstacle in their search for effective care: the systematic retreat of social care from mental health support. As pointed out in the recent Association of Directors of Adult Social Services’ discussion paper Mental Health into the Mainstream, many local authorities have spent the past decade devolving their mental health commissioning to NHS organisations. As a result, depression has become viewed more as a “medical” problem than a social one.

But depression remains a medical condition with a deeply rooted social foundation. Its risk factors (see box) read like a checklist for a typical client of adult social services. Medical therapies, however effective, can do little to alleviate social isolation, loneliness and poor socio-economic status. Only social care can help re-establish older people’s links with their communities and improve their access to support services.

“As well as improving diagnosis and treatment in primary care, more needs to be done to promote the simple activities that many older people can do for themselves to stay mentally healthy, such as exercise, volunteering, and joining local clubs,” says Simon Lawton-Smith, head of policy at the Mental Health Foundation.

“It is unacceptable that older people living in the UK are being denied such vital help, and that opportunities to prevent them becoming depressed are being ignored.”

There are some encouraging signs that the days of age discrimination within depression care may be numbered. The forthcoming Equality Bill will outlaw age discrimination in the provision of goods and services, including NHS treatment and social care. The National Service Framework for Older People requires that by 2011 every health district should have a fully resourced specialist service for older age mental health.

Care services minister Ivan Lewis says he “expects health and social care professionals, working in partnership with the voluntary sector and families, to prevent depression among older people and ensure appropriate treatment when necessary”.

There are, of course, countless examples of community projects run by local authorities and the voluntary sector throughout the country that help to reduce the social isolation of elderly people.

However, it will require a significant investment in these preventive services as well as treatment and support if age discrimination within depression care is to be eliminated. The Royal Society of Psychiatrists estimates that by 2051 there could be as many as five million older people with depression in the UK. Even at current levels it would cost £2bn to eliminate age discrimination in mental health services in England, according to a recent Department of Health-funded study .

But unless such an investment is made, depression care for the elderly will remain fragmented between health and social care and adult and older people’s mental health services. And wherever these arbitrary divisions are made, older people will continue to find themselves on the wrong side.

Relevant research

Age Concern report

Study of nursing and residential homes

Review of the National Service Framework for Older People

Mental Health into the Mainstream

DH-funded study

This article is published in the 18 September edition of Community Care magazine under the headline: This is a job for social care?