Suffering in silence - a time to speak up

11 February 2019

Dr Amanda Thompsell FRPsych. Following training at Charing Cross (Imperial College), London, Amanda worked as a GP before retraining as a psychiatrist and specialising in Old Age Psychiatry. Initially she worked as a consultant for an outreach team into care homes and then in liaison psychiatry. Currently Amanda works as a consultant at the South London and Maudsley NHS Trust with responsibility for a specialist care unit for older adults. She is the Chair of the Faculty of Old Age Psychiatry at the Royal College of Psychiatrists.

“I went in [to the doctor’s] going to tell him and ended up telling him I had back aches, pains and so … it went on and on… but because of all the stigma of the names that were used for mental health, people of my class then … would not have said mental health … we’d have said “nutcase”,” round the bend”, “not the ticket,” even that put a label on me and also it was a form of weakness… that’s what my group thinks.

June Cook, aged 82
speaking on BBC Radio 4 “You and Yours”
19 November 2018

Both mental health and old age continue to attract stigma. It is hardly a surprise, therefore, that ageism in relation to mental health issues continues to blight society and that it remains a major problem in the NHS – the very institution intended to promote health and well-being.

There is no doubt that these forms of stigma continue to exist. A YouGov poll of over 2,000 British adults published in November 2018 for older people’s charity Independent Age, found that 24% of respondents aged 65+ felt uncomfortable about friends and family knowing they had depression, compared to just 7% for arthritis. This rose to nearly half (43%) who felt uncomfortable with others knowing they had schizophrenia.

It has also long been understood that this pervasive negative view of mental health issues in older people also applies to clinicians. Linden and Kurtz (2009) found that when doctors were given case studies of two identical patients with depression and asked to assess, diagnose and prescribe treatment for them (the only differences being their age: 39 in one case, 81 in the other) the diagnoses and treatments given to the younger patients were significantly more appropriate than those for the older patient with all the criteria to meet ICD10 diagnosis for depression. A more recent study in The Lancet by Morgan et al (2018) suggests that little has changed. This study of older people who had self-harmed found that they were less likely to be referred to specialist mental health services than younger adults, despite the higher risk of suicide in this group.

Where I work, in the faculty of Old Age Psychiatry at the Royal College of Psychiatrists, we have long seen it as essential to tackle this inequality in acknowledging and addressing older people’s mental health needs. It is a pervasive myth that nothing can be done for older people with a mental illness. The national data from IAPT services shows that the opposite is true and recovery rates for older people consistently outperform working age people. We see an urgent need to debunk this myth.

As a result, we launched a report, “Suffering in silence: age inequality in older people’s mental health care” examining the issue of age discrimination in the treatment of mental illness in older people in more depth. It discusses the evidence for and the negative impact of this discrimination on the health of older people.

The report considers how ageism plays out in design and service delivery and argues that the “ageless” generic approach to mental health services, serving adults of all ages in one place, has resulted in further age discrimination. The needs of older adults are best met in specialised mental health services which understand the complexity of older people’s needs and have the expertise to meet them.

The report makes four main recommendations:

  • for resources to be rebalanced towards older people based on solid data about the makeup of the local population - we are not asking for reductions in other mental health disciplines to fund this, but rather we are calling for additional resources to meet older people’s mental health needs as a priority for central expenditure planning;
  • that targeted services for older people are developed, such as crisis care (a recent survey of members of the Faculty of Old Age Psychiatry Royal College of Psychiatrists in 2018 found 19% had no crisis or home treatment team available for older adults);
  • to review the mental health workforce strategy to ensure that there are enough staff to meet the needs of older people; and
  • to raise public awareness. Just as we have made progress in raising public awareness of dementia, we now need to do the same for older people’s mental health generally. Society should recognise the impact of mental health problems on older people and their treatability.

This is not just about government: we all have our part to play in overcoming unconscious bias so that issues of stigma and of discrimination do not stand in the way of providing older people with access to the treatment that they need.

As the population ages, time is running out for all of us to get this right. Overcoming age discrimination in relation to mental health is a national priority.

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