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date: 31 May 2020

Barriers to Mental Healthcare Utilization

Abstract and Keywords

This chapter provides an overview of the literature on barriers to mental healthcare utilization experienced by older adults, critically evaluating progress towards reducing barriers. Barriers are divided into client (i.e. stigma, perception of need, attitudes), therapist (i.e. attitudes, training), and mental health system variables (i.e. access). Advances in integrated models of care are reviewed, including a discussion of those older adults who may not be well served by these models. Older populations in rural areas continue to face significant barriers to mental healthcare, although telehealth interventions are currently being evaluated and show promise. Research on barriers to mental healthcare rarely include ethnic minority elders and, although good conceptual models are available (e.g. Hwang et al. 2008), research has yet to investigate the multiple factors that limit access to care and ways to facilitate access. Finally, this chapter provides practice recommendations for reducing barriers to mental healthcare utilization.

Keywords: barriers, mental health, utilization, underserved, access

Introduction

I (CK) read a chapter that reviewed psychological service barriers when I was a budding geropsychologist (Gatz et al. 1985). It influenced me greatly. Now over twenty-five years have passed. Some barriers have been reduced (e.g. attitudes towards mental health utilization), but others have been woefully neglected (e.g. rural populations). Few studies have examined the broad range of psychological service barriers applicable to older adults. The purpose of this chapter is to evaluate progress towards reducing these barriers. Our goal with respect to barriers to mental healthcare utilization in older persons is to provide an overview of the current literature, highlight gaps in that literature, and highlight unique and innovative programmes for which there is empirical support.

Client Variables

Stigma

Do older adults hold more negative views of mental illness compared to younger adults? To date, findings have been inconsistent. Angermeyer and Dietrich (2006: 170) reviewed research between 1990 and 2004, examining age differences in attitudes towards people with mental illness. This comprehensive literature review included studies from a broad range of primarily European countries and included thirty-three national and twenty-nine local and regional samples. Studies focused on both mental illness in general and specific mental health problems, including severe and persistent disorders. They reported that negative attitudes were positively associated with age in thirty-two studies, negatively associated with age in one study, with no relationship found in ten studies. Other research from (p. 950) North America failed to find age differences in stigma (Cook and Wang 2010; Pepin, Segal, and Coolidge 2009; Segal et al. 2005). Yet, as part of the Changing Minds campaign in Great Britain, a population survey of 1725 individuals was conducted in 1998 and again in 2003. In both surveys, the most negative views were held by those between the ages of 16 and 19 for six of the seven mental health problems that were included (Crisp et al. 2005). In part, these inconsistent results may have to do with the multidimensional nature of stigma and different methods of assessment. For example, Segal et al. (2005: 365) found that older adults believed that those with mental illness had poorer social and interpersonal skills (e.g. were more embarrassing or untrustworthy), yet did not differ from younger respondents regarding beliefs about incurability or dangerousness.

As Angermeyer and Dietrich (2006: 170) indicated, the extent to which age differences in stigma represent an ageing or cohort effect remains unknown. If they are due to a cohort effect, one might hope that future generations would hold less stigmatizing views due to clinical, research, and policy initiatives on stigma reduction. Pescosolido et al. (2010: 1321–1330) analysed data from the 1996 and 2006 General Social Survey to determine whether attitudes towards those with schizophrenia, depression, and alcohol dependence had changed over time. They found that, although respondents were more likely to endorse neurobiological explanations for these disorders, this did not lead to decreases in stigma. Levels of stigma remained high and, in fact, increased for some stigma indicators for schizophrenia and alcohol dependence (Pescosolido et al. 2010: 1323). Moreover, stigma against persons with Alzheimer’s disease and their family members has been reported in numerous studies by Werner and colleagues (Werner and Giveon 2008; Werner and Heinik 2008) and is a significant predictor of care-giver burden (Werner et al. 2012). Thus, the 1990s Decade of the Brain, with its increased emphasis on neurobiological and genetic aetiologies, does not appear to have had an impact on stigmatizing attitudes. These data attest to the pervasiveness, stability, and negative consequences of these attitudes and suggest the continued importance of stigma reduction campaigns for future cohorts of older adults.

Ideally, stigma reduction efforts should involve inter-agency collaborations. In the Canadian context, the Canadian Coalition for Seniors’ Mental Health is partnering with the Mental Health Commission of Canada (MMCC) to better understand the unique needs and experiences of stigma in the older population. Building on the Technical Consensus Statement produced by the Old Age Psychiatry section of the World Psychiatric Association and the World Health Organization (Graham et al. 2003), and the conceptual model of Link and Phelan (2001), Canadian researchers are engaged in a programme of research investigating the unique needs and experience of stigma among older adults. Recognizing that anti-stigma efforts must target multiple stakeholders, initial work has focused on surveying health providers in the ageing sector. Preliminary data suggest that more than half of respondents did not have anti-stigma programmes in place, and over one-third indicated that they simply had not thought of it. Thus, there is much to be done in the area of stigma reduction among healthcare professionals working with older adults (Wilson 2012). Although stigma continues to be prevalent in society in general, research suggests that it is not the most significant barrier to help-seeking among older adults and that other factors may more strongly account for patterns of under-utilization (Mackenzie, Pagura, and Sareen 2010; Mackenzie et al. 2008; Pepin et al. 2009).

(p. 951) Perception of need and attitudes towards mental health treatment

What are the strongest predictors of mental heath service use among older adults? There is considerable support in the literature for perceived need as the strongest predictor of mental health service use among older adults (Karlin, Duffy, and Gleaves 2008), including those with anxiety disorders and symptoms (Scott et al. 2010). There is also compelling evidence from two studies with large, nationally representative samples that older adults have lower levels of perceived need compared to their younger counterparts (Karlin et al. 2008; Mackenzie et al. 2010). Similarly, Garrido et al. (2009: 707) reported that, in their sample of adults 65 years and older, perceived need was lower among those of advanced age. Even among older adults who had a psychiatric diagnosis (mood, anxiety, or substance-related disorder), only 47% perceived a need for treatment, with the majority of these (69.2%) citing a preference for ‘handling problems themselves’ (Mackenzie et al. 2010). This tendency was also observed by Garrido et al. (2011: 53), who reported that, of those who indicated a perceived need for care but delayed seeking that care for at least a month, 75.4% wanted to handle the problem on their own. However, results are preliminary because, although both studies involved large datasets of older adults, these findings are based on small sub-samples of thirty-six (Mackenzie et al. 2010) and forty-three (Garrido et al. 2011) who met the inclusionary diagnostic criteria and perceived a need for care.

In one of the largest studies to date, Garrido et al. (2009: 704–712) used the Collaborative Psychiatric Epidemiology Survey to assess the correlates of perceived need among 1339 adults, 65 years of age and older (mean age of 74.6 years), residing in the community. Consistent with the findings of Mackenzie et al. (2010: 1103–1115), only half of the respondents who met diagnostic criteria for major depressive disorder (MDD) or generalized anxiety disorder (GAD) within the past year perceived a need for care. Overall, perceived need was highest among those who met criteria for MDD or GAD; however, subthreshold GAD and the number of symptoms of depression and anxiety were also significantly related to greater perceived need. Alcohol abuse and/or dependence was associated with greater perceived need among those with a diagnosis of GAD but not MDD within the past year. Lifetime occurrence of chronic health problems was associated with greater perceived need but measures of general health were not, suggesting that those who have a history of interacting with health systems are more likely to perceive a need for mental healthcare.

How do older adults view mental health services? A growing body of literature suggests that older adults have generally favourable views (James and Buttle 2008; Mackenzie, Gekoski, and Knox 2006; Woodward and Pachana 2009) and that there are no age differences in the willingness to seek out professional psychological help (Segal et al. 2005). Using the National Comorbidity Survey Replication, Mackenzie et al. (2008: 1014) found that over 80% of adults 55 and older held positive help-seeking attitudes. The most positive views were held by the first wave of the baby boom generation (ages 55 to 64), who were almost three times as likely to endorse positive views compared to young adults (ages 18 to 24). However, for the total sample, those with a diagnosed mood or anxiety disorder held the most negative views within the past year. Mackenzie et al. (2006: 577) found that never-married older adults were most likely to be open to seeking help. In addition, Mackenzie et al. (2010: 1110) found that, in their sample of older adults, advanced age was related to help (p. 952) seeking. Among those who were 75 years and older, very few who perceived a need did not seek help for it, indicating a significant age difference between the young-old and old-old. Further research is needed to better understand the relationship between perception of need and help seeking, and why this may be stronger among the very old.

While these results are encouraging, it is important to emphasize that these samples of older adults tend to be better educated, healthier, and ethnically homogeneous. Furthermore, these data suggest that many older adults with mental health problems do not perceive a need for care and may have more negative attitudes towards psychological services. This is consistent with the findings of Crabb and Hunsley (2006: 306), who reported that depressed older adults under-utilize mental health services.

Mental health literacy

Can those who work with older adults recognize a mental health problem? An important initiative that is vital to overcoming barriers to mental health utilization is the training of those individuals who interact with older adults in the course of their daily activities, for example, those working in the continuum of medical and supportive services that are available to older adults. Australia is the leader in mental health literacy, defined as ‘knowledge and beliefs about mental disorders which aid in their recognition, management, or prevention’ (Jorm et al. 1997: 182). The Mental Health First Aid Training (MHFA) and Research Program was developed in Australia to promote mental health literacy, and has been adapted for implementation in fifteen other countries (Jorm and Kitchener 2011). Jorm (2012: 238), in his review of evaluated programmes, states ‘there is good evidence that the mental health literacy of a whole community can be improved’. However, these programmes typically involve community campaigns (e.g. beyondblue in Australia), or outreach to younger adults, cultural minorities, or people in developing countries. There is tremendous potential for extending mental health literacy programmes to older adults, their family members, and those who work with seniors. For example, direct care workers are in a pivotal position to benefit from mental health literacy training, as they are important gatekeepers in the detection of mental health problems among frail and isolated seniors, a particularly vulnerable group. To the best of our knowledge, Singapore is the only country to offer Mental Health First Aid with a specific focus on the older person (http://www.mhfa.com.sg/mhfa-op.html). The ability to recognize the signs and symptoms of a mental health problem is the first step in getting appropriate assessment and treatment for older adults.

Therapist Variables

Attitudes towards older adults

To what extent are attitudes towards older adults significant barriers to mental health treatment? There are two broad categories of barriers. First, mental health professionals who begin working with older adults may be concerned about how much specialized knowledge is needed. Concerns about competency may lead to a general reluctance to engage older (p. 953) adults in clinical practice. Competency tools such as the Pikes Peak measure and the recognition of geropsychology as a proficiency area of practice by the American Psychological Association in 2010 are positive steps towards overcoming this barrier. Furthermore, there are a variety of ways of integrating geropsychology content into pre-doctoral training programmes in clinical psychology (Qualls et al. 2010).

Second, therapists’ and societal attitudes about older adults’ prognosis and worthiness have been viewed as significant barriers, particularly in light of the severe scarcity of mental health resources and many competing at-risk groups, including children. In 2002, a review by Robb, Chen, and Haley (1–12) indicated that older adults are treated differently by the medical system, for example, in terms of screening and access to treatment. However it was unclear whether this was due to an age bias or other factors. There have been surprisingly few studies of age bias among mental health professionals, and those that have been carried out primarily utilize vignette methodologies. Collectively, these studies suggest that age bias does not appear to influence the diagnostic process, at least in the case of depression, but that it does contribute to more negative attitudes towards treatment and perceptions of poorer prognosis among US psychologists and trainees and Australian psychologists and counsellors (Helmes and Gee 2003; Meeks 1990). Interestingly, when asked directly about barriers to mental healthcare, both younger and older adults ranked ageism as the least influential barrier (Pepin et al. 2009).

Although age biases are often thought of as negative, equally important are positive biases. Knight (2010: 109–110) discussed the role of positive ageing stereotypes among supervisees and suggested that therapists in training (and even more experienced therapists) may have difficulty identifying substance abuse or cognitive impairment in a client. These biases may prevent older adults from getting the help that they need and are potentially just as serious as negative biases. More generally, students are attracted to clinical geropsychology because they truly like and care about older adults and this may contribute to ‘blind spots’, whereby they tend to view their clients through the lens of positive stereotypes of ageing. Knight (2010: 113–114) also noted that older trainees or therapists that feel negatively about their own ageing may convey an inappropriately positive view of age-related losses, minimizing the impact they have on older clients.

Training issues

Are we making progress towards addressing the well-documented lack of trained professionals in geriatric mental health (Institute of Medicine 2012)? There have been significant developments in the area of education and training, most notably the development of the Pikes Peak model of training in geropsychology (Knight et al. 2009) and the associated measure of competency, the Pikes Peak Geropsychology Knowledge and Skill Assessment Tool (Karel et al. 2012a). This tool was recently used in an online survey of 764 clinical and counselling graduate students in the US, Canada, Australia, and New Zealand (Woodhead et al. 2013). Approximately 80% of respondents indicated that they anticipated working with older adults in the future; self-rated competencies were positively and significantly related to ageing-related course work, practicum hours with older clients, and greater faculty with ageing-related interests. Exposure to course work and clinical practica in ageing have consistently been found to predict interest in working with this population in (p. 954) both psychology (Koder and Helmes 2008; Pachana et al. 2010) and social work trainees (Cummings and Galambos 2002). The barriers that were most often cited to providing additional training were an inability to recruit staff and difficulties in finding appropriate practicum experiences.

Not only is there a marked lack of mental health professionals trained to work with older adults, the training that they do receive appears to reflect the broader trend towards the assessment and diagnosis of cognitive disorders to the neglect of treatment, in spite of the demonstrated efficacy of many psychological interventions. For example, geropsychology training in accredited clinical and counselling internship programmes in Canada provides more training on diagnosis and assessment and less on individual psychotherapy with older adults (Konnert, Dobson, and Watt 2009). Of those internships with geropsychology rotations, only 47.6% of US and 63.6% of Canadian sites offered individual psychotherapy training experiences (Pachana et al. 2010). Opportunities for this type of experience were significantly higher in Australia, with 85.7% of training sites reporting that they offered this training.

One of the exciting training developments has been the growth of doctoral programmes that offer training in primary care settings, for example, at the University of Colorado at Colorado Springs (Novotney 2012) and Yeshiva University (Zweig, Siegel, and Snyder 2006). In the US, the federally sponsored Graduate Psychology Education programme provides funds to train geropsychology doctoral students in primary care, and preliminary data are very promising. In short, ‘geropsychology training in primary care represents a win-win opportunity for doctoral psychology programmes, physicians and healthcare systems, and older adults in need of services’ (Zweig et al. 2006: 27). These programmes are particularly effective at targeting older adults of minority status, a group that experiences significant barriers to mental healthcare. Increasingly, psychologists and other mental health providers will work in diverse settings that serve older adults, each with their own unique organizational structures. Currently, setting-specific competencies are considered a core aspect of training in geropsychology competencies (Knight et al. 2009).

Mental Health System Variables

Knight and Sayegh (2011: 228–243) described the fragmented, multisystem network of mental healthcare for older adults in the US and the historical factors that influenced its development. The various systems of care include specialty mental health, acute medical, long-term, dementia, and substance abuse. Often these systems have conflicting cultures, policies, and procedures, and compete for limited funding. Moreover, services are delivered as if one size fits all, with no recognition that older adults have diverse mental health needs. For example, those with chronic mental illness have very different needs from those with late-onset disorders.

Concerns about access

Can older people find a therapist? In the spring of 2006, the Committee on Aging of the Group for the Advancement of Psychiatry collaborated with Jeanne Phillips, the author of the daily column ‘Dear Abby’, the most widely syndicated in the world with more than (p. 955) 10 000 letters and e-mails per week (Koh et al. 2010). In her column, she solicited information about, ‘how older people feel about mental health problems, where you seek help for them, what you feel needs to be done to improve services, and whether you’d like more mental health services than you are getting now’ (Koh et al. 2010: 1146). Of the over eight hundred replies received, the overwhelming concern was access to a mental health professional. While this was not a particularly scientific study, the results reflect those of Pepin et al. (2009: 774), who reported that on the Barriers to Mental Health Services Scale, the subscale ‘belief about inability to find a psychotherapist’ was the highest and second to highest ranked barrier for older and younger adults respectively. Also ranked highly were concerns about a psychotherapist’s qualifications, a very realistic perception given the shortage of mental health providers with specialized training. Similarly, among older adults with a perceived need for mental healthcare, concerns about where to go or who to see were ranked as the first (Karlin et al. 2008) and second (Mackenzie et al. 2010) most significant barriers.

Knight and Shurgot (2008: 454) made the case that future cohorts of older adults will be more likely to seek psychological services and Mackenzie et al. (2008: 1016) reported that the first wave of baby boomers (ages 55–64) held the most favourable attitudes towards mental health seeking. In addition, the baby boom cohort may be more sophisticated in terms of their understanding of the efficaciousness of psychological treatments. Therefore, concerns about access will not only include finding competent and trained providers, but also obtaining evidence-based treatments. Gatz (2007: 52–53) described evidence hurdles, those issues that research has failed to address well. These include an absence of literature but also issues that are relevant to the efficacy–effectiveness continuum, that is, moving from the lab to the real-world delivery of interventions (e.g. sampling, comorbidity, fidelity) where contextual factors play an important role in the delivery of psychological interventions to older adults.

There is also a pressing need to disseminate evidence-based interventions more widely to older adults, and, globally, health agencies have a strong commitment (both at the policy level and with dedicated funding) to supporting knowledge uptake and translational activities. The World Health Organization’s (WHO) recent publication provides a framework for knowledge translation in ageing and health, including ‘push’ and ‘pull’ strategies for promoting evidence-based practice (WHO 2012). Many of these strategies have great potential for overcoming barriers to the uptake of evidence-based psychological interventions with older adults. Eli (2006: 121–125) provides a comprehensive review of the barriers depressed older adults face in seeking evidence-based care, and provides useful strategies for translating research into practice.

Recently, Ward et al. (2012: 298) argued that conceptualizations of knowledge translation need to go beyond simply examining barriers and enablers in the relationship between research and practice. Their qualitative data examined how knowledge exchange unfolded in real time within three service delivery teams in a mental health organization in the UK. Ward et al. (2012: 302) make the important point that knowledge uptake is a process that is highly contextual and that ‘context’ has typically been narrowly defined. More broadly, knowledge uptake is a social and political process that involves, among other things, a good understanding of norms, professional identities, and individual beliefs. As clinical geropsychologists continue to deliver services in a variety of contexts, it will become important to better understand these contexts in order to facilitate the knowledge uptake of evidence-based psychological treatments. For example, long-term care residents are among the most underserved older adults in terms of their mental health needs. If depression is (p. 956) viewed as normative in these environments and if those who work in long-term care do not see themselves as mental health providers, then the probability that evidence-based mental health treatments will be provided is low.

Integrated models of care

It is now widely recognized that integrated models of care are the wave of the future, as outlined in the document Blueprint for Change: Achieving Integrated Health Care for an Aging Population (American Psychological Association 2008). Mackenzie et al. (2006: 579) and James and Buttle (2008: 38) reported that older adults were more likely to seek psychological help from a primary care physician than a mental health professional. Unfortunately, the mental healthcare they receive in primary care settings is often inadequate (Moak 2011). As noted by Karel et al. (2012b: 189–190) and Moak (2011: 278–280), mental healthcare is particularly effective when integrated into primary and community care, and they provide examples of evaluated programmes designed to treat a range of mental health problems in these contexts. (See also Armento and Stanley on psychological interventions in primary care settings in this Handbook.)

In a randomized trial, Bartels et al. (2004: 1455–1462) compared integrated mental healthcare with enhanced referral to specialty mental health clinics among 2022 patients (mean age 73.5 years) with depression, anxiety, or at-risk alcohol use, across ten sites. Various indices of treatment engagement clearly indicated the superiority of integrated care. Comparing integrated to specialized care respectively, 71% vs 49% of clients made at least one visit, and mean number of visits was 3.04 vs 1.91. In addition, two particularly important findings emerged from the data. First, the integrated model appeared to function particularly well for individuals with at-risk alcohol use and those with active suicidal ideation. Second, treatment engagement was positively related to closer proximity of mental health/substance use services to primary care. Bartels et al. (2004: 1460) suggested that integration should be viewed along a continuum across multiple dimensions that involve not only physical proximity but also temporal proximity, communication, and collaboration across health and mental health providers, range of mental health services, and the degree to which billing for physical and mental health services can be coordinated and streamlined.

The first step in integrated care involves enhanced outreach and referral capacity. In Singapore, the Community-based Early Psychiatric Interventional Strategy (CEPIS) utilized community outreach strategies at seventy-six sites, including active screening programmes, psychoeducation, and case manager support to enhance access and primary care referrals for depression among seniors (Nyunt et al. 2009). Of the 4633 participants (mean age 73.7), 370 screened positive for depression. Of these, fewer than a quarter perceived a need for help and, in the past year, only 10.3% sought treatment. The CEPIS outreach strategies improved the rate of referral for further assessment and treatment to 73.8%. The majority of the referrals were for older adults with subsyndromal depression, a group that is at high risk for major depressive disorder. Notably, the study sample was comprised of older individuals (aged 70+) who were of lower socio-economic status and in poor health, a group that is at greater risk of mental health problems and an important target group for preventive interventions.

(p. 957) On a cautionary note, Moak (2011: 279–280) suggests that integrated care is not suitable for all mental health problems and some older adults with more severe problems may need more intensive services. In addition, integrating mental healthcare into primary care will only be successful if staffed by mental health professionals with geriatric training. The workforce shortage and acute funding deficits in primary care limit the potential for new and innovative programmes such as integrated care. In the US, recent changes to reimbursement plans increased payment to some primary care providers while at the same time reduced fees for specialized providers, in particular those with geriatric mental health training. As stated by Moak (2011:281), ‘the detrimental impact of this on the development of geriatric mental health services cannot be underestimated’.

Often overlooked in this discussion is the fact that many older adults with serious mobility problems or lack of transportation are unable to benefit from mental health treatment in primary care or specialized programmes. Davitt and Gellis (2011: 314–315) discussed the complexities of providing mental health services through Medicare home care benefits in the US, identifying two specific barriers. First, mental health is assessed in the context of a much longer and more burdensome evaluation protocol (i.e. the Outcome and Assessment Information Set–C) and the mental health items lack sensitivity and specificity. Furthermore, those administering the items may lack sufficient training in mental health screening. Second, Medicare policy restricts the provision of mental health services to psychiatrically trained nurses, effectively reducing access to other potential mental health providers, such as social workers. This policy essentially serves to curtail costs and ultimately restricts the availability of mental health services to homebound older adults. Davitt and Gellis (2011: 317–320) provide recommendations in the practice, policy, and research arenas that have the potential to improve access to care. For example, social workers (or other mental health professionals) could train those doing home care assessments in detecting mental health problems and making appropriate referrals. They could also be more involved in providing treatment to home care clients, a particularly important initiative given that many home health agencies do not have psychiatric nurses on staff, especially in rural areas.

Special Populations

Older populations in rural areas

Barriers to Mental Healthcare Utilization

Figure 45.1 The three As of barriers to mental healthcare for older populations in rural areas.

The proportion of older adults living in rural areas is growing due to the global increase of persons reaching old age and the increasing urban migration of younger people from rural areas (Kaufman et al. 2007). Jameson and Blank (2007: 284–287) provide an excellent overview of the problems facing rural residents of all ages who need mental healthcare. These problems are particularly acute among older rural residents. Barriers to care can be broadly grouped into poor availability, limited accessibility, and acceptability of mental health services (see Figure 45.1, Fox, Merwin, and Blank 1995).

In addition to these barriers, the heterogeneity of rural older persons is rarely addressed. Characteristics such as race, ethnicity, religion, socio-economic status, distance from urban centres, and population density differ significantly between, and even within, rural communities, which create subgroups of individuals that experience unique challenges (Kaufman (p. 958) et al. 2007). Focus groups conducted in Canadian rural communities revealed four types of rural older persons: community active, stoic, frail, and marginalized, and each had different perceptions of and needs for services (Keating and Eales 2012). This type of information offers essential and practical strategies for the development of effective mental health services to meet diverse needs in rural communities. All too often, programmes that work in urban settings are assumed to be equally effective in rural settings; however, this top-down approach fails to appreciate the distinct social and cultural milieux within rural environments. In contrast, bottom-up approaches have greater potential to create programmes that are more palatable to older adults living in rural areas and may be more sustainable in these environments (Bull et al. 2001).

An innovative approach was employed by the ElderLynk programme, which served to link existing mental health and social services with primary care providers and provided geriatric mental health education to professionals and the general public (McGovern et al. 2008). The researchers employed a community-based participatory research process that included community partners and stakeholders (e.g. local practitioners, community members) in the development, implementation, and evaluation of the programme. Although not without its challenges, this approach assisted in bringing together mental health providers, (p. 959) enhanced cooperation and increased community involvement, and may serve as a useful model for creating culturally sensitive, community-specific services (Blevins, Morton, and McGovern 2008).

Furthermore, there is a strong need for the evaluation of innovative service delivery among rural older cohorts in order to inform practice and research, as presently outcome evaluations of programmes in place fail to be conducted or appropriately disseminated. Kaufman and colleagues (2007: 355–361) employed a helpful strategy by sharing the challenges their team encountered in recruitment (e.g. irregular referrals, suspicious attitudes) and provision of services (e.g. travel time, illiteracy, stigma, poverty) as part of the Project to Enhance Aged Rural Living that examined the effectiveness of providing cognitive-behaviour therapy (CBT) to older adults living in such areas. By sharing the challenges they encountered, and how they accommodated for them, the authors effectively disseminated implications for practice and research. Within a limited population of researchers and service providers that specialize in geriatric rural mental health, such open and active discourse is particularly essential to allow for significant progress in the design, evaluation, and provision of mental health services to rural older adults.

Telehealth and rural older adults

Technology-based service delivery methods (e.g. telephone, email, videoconferencing, website access), referred to as telehealth, have increased access to cost-effective, high-quality mental healthcare for older persons living in rural areas, and have provided many creative possibilities for providing care (Buckwalter et al. 2002). Most notably, assessment and treatment via telehealth have proven comparable to face-to-face approaches among older adults, with similar patient satisfaction (Mitka 2003).

What types of telehealth programmes are available for rural older adults and/or their care-givers? The University of California Davis Medical Center eMental Health Consultation Service serves as a comprehensive ‘virtual mental health clinic’ that successfully provides psychiatric (i.e. medication consultation) and psychological (e.g. brief solution-focused therapy and CBT) clinical services, as well as consultations and education to rural primary care clinics through telehealth, secure email, and telephone (Neufeld et al. 2007). Moreover, telepsychiatry consultations for depression and dementia-related behaviour problems have been employed in a rural nursing facility (Johnston and Jones 2001), with the ability to respond promptly to residents’ clinical needs, efficient use of consultants’ time, greater follow-through of recommendations, and high levels of family and resident satisfaction with the quality of care provided. Computerized therapy programmes, whereby therapy interventions are presented on a computer in place of face-to-face contact with a therapist, are also being evaluated. A four-year prospective randomized controlled trial is currently underway comparing the effectiveness of evidence-based treatments for depression in older persons delivered via in-home videophone or traditional face-to-face services in such rural areas (Egede et al. 2009). Furthermore, use of telehealth in long-term care (LTC) facilities may have an even greater role than in community settings, as the LTC sector is generally disconnected from specialist services, including mental health services. Notably, many of the services that are provided on site in urban LTC facilities can be provided via telehealth to rural LTC facilities (Gray et al. 2012: 145). The use of telehealth in (p. 960) such settings would also be more economically viable as multiple residents, staff, and family members could use the same equipment (Gray et al. 2012).

In addition to providing services to older adults, telehealth interventions have the potential to assist rural family care-givers, for example the Telehelp Line for Caregivers, which provides supportive services and resources through a call-in helpline and structured telephone counselling sessions (Dollinger and Chwalisz 2011). In addition, there is great potential for the use of internet-based intervention programmes for care-givers, which have yielded outcomes similar to those of face-to-face support groups (Marziali and Garcia 2011). Although use of technology with older persons raises concerns about technological skills, recent programmes have incorporated simplified computer training manuals and regular support, in addition to simplifying technology (e.g. using remote control devices), as well as making accommodations for individuals with cognitive, intellectual, and sensory deficits (Buckwalter et al. 2002). In addition to providing greater access to services, videoconferencing via the internet has also proven useful in enhancing professional development for isolated rural professionals by increasing access to clinical supervision, improved consultation, and training programmes to front-line staff (Troisi 2001).

Some challenges remain with the use of telehealth, such as inconsistent reimbursement and compensation by third-party payers, initial direct costs of technology equipment and software, perceived ‘emotional distance’ between consumers and providers, nervousness about using new technologies, problems with licensure, and weaker technological infrastructure of rural communities (Jameson and Blank 2007; Whitten 2001). A recent review of Medicare expenditure in Australia for psychiatric consultations showed that consultations delivered via videoconference are currently being under-utilized given the level of funding provided for such consultations (Smith et al. 2012:170). It is important to further examine the barriers to using telehealth as part of regular care. These include the infrastructure for using telehealth, such as equipment and software, as well as clinical and administrative support systems required to support telehealth in the clinical environment (Smith et al. 2012: 170). Furthermore, the quality of research examining the clinical effectiveness of use of telehealth with older adults has been limited and there is a great need for more robust studies and randomized controlled trials (Brignell, Wootton, and Gray 2007). Much of this research has addressed a limited number of questions and is frequently focused on user acceptance and reliability (Edirippulige et al. 2013). Future studies should examine telehealth interventions more broadly and avoid focusing on a single aspect of care provided by a given specialty. For example, many studies examining telehealth in LTC focus generally on the reliability of dementia diagnoses provided by psychiatry (Edirippulige et al. 2013).

Overall, with the proliferation of technology in our society, and the increasing familiarity with technology among baby boomers, it is likely that telehealth will receive increased acceptance and use among providers and consumers. Although further evaluation of the efficacy and effectiveness of telehealth in service provision for older persons in rural areas is needed, this service modality holds significant promise.

Ethnic minority groups

Barriers to Mental Healthcare Utilization

Figure 45.2 The Cultural Influences on Mental Health (CIMH) model.

Surveys that address barriers to mental healthcare utilization among older adults often do not include ethnic minorities, but report on samples that are almost exclusively Caucasian, (p. 961) in spite of the fact that older persons from minority backgrounds are at greater risk for mental health problems and are less likely to utilize mental health services (Sorkin, Pham, and Ngo-Metzger 2009). Reasons for under-utilization are complex and varied, and must be understood in the context of conceptual frameworks, such as the Cultural Influences on Mental Health Model (see Figure 45.2; Hwang et al. 2008). These authors provide an excellent overview of the multiple pathways and barriers to help seeking among culturally diverse groups, recognizing the unique influences of immigration background (e.g. refugees), acculturation and enculturation, racism and discrimination, socio-economic status, stigma, and attitudes/beliefs that are unique to specific groups. In general, the literature on barriers to mental healthcare among older ethnic minority groups is very sparse.

Much of the research has focused on older Asian populations, reflecting the increased numbers of Asian immigrants in many countries. For example, in Canada from 1981 to 2006, the percentage of visible minorities grew from 4.7% to 16.2% of Canada’s total population, with Asians and South Asians comprising the two largest groups (Natural Resources Canada 2009). By 2017, this percentage is expected to increase from 19% to 23%, depending on the growth scenario utilized (Statistics Canada 2005). This, coupled with an ageing population, has led to a significant increase in the number of older Asians living in Canada. Moreover, the prevalence of depressive symptoms among older Chinese-Canadians is twice as high as estimates in the general older Canadian population (Lai 2000), a finding that is consistent with US data (Mui and Kang 2006).

The literature on barriers to mental healthcare among Asian older adults has focused on mental health literacy, the expression of psychological distress, acculturation and enculturation, and cultural attitudes and beliefs. Using a case vignette methodology, depression literacy was found to be poorer among older (mean age = 70) Chinese immigrants compared to a population-based survey of Canadian-born older adults, with 11.3% and 74% respectively correctly identifying depression (Tieu, Konnert, and Wang 2010). In addition, the (p. 962) majority (52.8%) of Chinese older persons believed that the person depicted in the vignette would fully or partially recover from depression without receiving professional help, in contrast to 9.4% of Canadian-born older adults. General practitioners were viewed as helpful by 43.4% of Chinese participants and 89.3% of Canadian-born participants. There is some evidence that Chinese people express distress somatically; however, not all research supports this finding (Ryder et al. 2008). Cultural differences in the expression of depression may account, in part, for the low recognition of depression in the vignette. In addition, significantly more Chinese older adults endorsed the views that full or partial recovery from depression would occur without professional intervention and that general practitioners were not particularly helpful (Tieu et al. 2010). These beliefs may act as significant barriers to help seeking among older Chinese persons. This is particularly true given that general practitioners are the major treatment providers for mental health problems and act as gatekeepers to the mental health system in Canada.

In a study specifically designed to assess attitudes towards seeking mental health services, 150 Chinese-Canadian immigrants, mean age 74 years (range = 55 to 95 years), were interviewed in either Mandarin or Cantonese using the Inventory of Attitudes toward Seeking Mental Health Services (IASMHS) scale (Mackenzie et al. 2004; Tieu and Konnert 2012). Participants who were younger, married, and proficient in English reported significantly more positive attitudes towards seeking mental health services, as did those with more perceived social support. The results of this study clearly indicate the importance of English literacy in attitudes towards mental health services, and the need for providing mental health services in multiple languages. The results also reinforce the challenges associated with changing attitudinal barriers among older Chinese adults with less perceived support who are not married, as these individuals may be most vulnerable to mental health problems.

Other factors that may act as barriers to mental health services include acculturation/enculturation and attitudes and beliefs. Models of acculturation have become more complex, recognizing the dual processes of acculturation (i.e. adopting the cultural norms of the dominant society) and enculturation (i.e. retaining the norms of the indigenous culture) (Ryder, Alden, and Paulus 2000). Where older adults fall on these two dimensions may have significant implications for their attitudes about mental healthcare utilization and their willingness to access these resources. Moreover, because family members are often pivotal in helping older adults access the mental health system, their acculturation/enculturation may also play a role, with a potential for conflict if, for example, the younger generation is more accepting of mental health services but these attitudes are not shared by older generations.

Beliefs and values of the indigenous culture also play a significant role. For example, traditional Chinese medicine takes a holistic view, integrating mind, body, and spirit with an emphasis on balance in life and harmony with nature (Lai and Surood 2009). Psychiatric illnesses have been attributed to ghosts, evil spirits, infection, injuries, intoxication, nutritional deficiency, somatic illness, and congenital factors. As a result, there may be different pathways to seeking help among older Chinese persons, for example alternative and complementary approaches. Confucianism, Taoism, and Buddhism heavily influence Chinese beliefs, and cultural values such as filial piety and the preservation of face may play a significant role in accessing mental health services. To date, research in this area has focused on younger Chinese adults (e.g. Yang, Phelan, and Link 2008), with virtually no attention paid to how these factors may influence access to mental healthcare among older adults across a variety of ethnic backgrounds.

(p. 963) Implications for Practice

What do practitioners need to know? Perceiving a need for mental healthcare is the best determinant of accessing care. Mental health literacy initiatives are important because they aid in the detection and recognition of mental health problems, potentially increasing perceptions of need. For those who are reluctant to seek help, providing information that many mental health disorders are very treatable with time-limited and focused interventions may also increase the likelihood of seeking help. In addition, older adults have generally favourable views of mental health services. However, they are concerned about how to find a therapist who is qualified and familiar with issues that are relevant to them. It is not uncommon for mental health professionals to advertise specific areas of expertise and populations of interest (depression, children and adolescence) within their practice domains. If mental health professionals have an interest in and familiarity with working with older adults, this information should be advertised and broadly disseminated to venues and in ways that are most likely to reach older adults (e.g. seniors’ magazines, seniors’ centres, primary care physicians, etc.). Most importantly, a consistent theme in the geropsychology literature is the need to embed mental health services into places where older adults are. Thus, practitioners need to think creatively about how to work within the continuum of services for older adults, and increase their visibility in settings where older adults live, work or volunteer, and engage in recreation.

Summary

One of the exciting, yet challenging aspects of being a gerontologist is thinking about how what we know today will translate to future cohorts of older persons. How can we overcome barriers to mental healthcare both now and in the future? Several findings from this review suggest some promising avenues of research. First, the literature strongly suggests that perceived need is the best predictor of mental health service use (Karlin et al. 2008; Scott et al. 2010) and that younger adults have greater levels of perceived need than older adults (Mackenzie et al. 2010). Although these findings are cross-sectional, it is likely that future cohorts will perceive a need for mental health services. Educational campaigns are promising. There is strong evidence that mental health literacy campaigns are effective for whole communities and countries, such as Australia, Germany, and Norway (Jorm 2012). Recognition of need is the first step but mental health literacy also encompasses knowledge of evidence-based treatments, the qualifications and skills to look for in a mental health therapist, and effective self-help strategies. It also has clear links to universal and/or targeted prevention strategies. The question remains how best to capitalize on the success of mental health literacy efforts to overcome barriers to mental healthcare among older adults, both now and in the future.

Second, what can we do to meet the growing demand for mental health treatment among future cohorts, particularly those older adults who are most vulnerable? Training initiatives focusing on core competencies in clinical geropsychology and assessment measures, such as the Pikes Peak tool, are welcome additions to the training landscape. The move towards (p. 964) setting-specific competencies is also laudable, and hopefully will extend to a wider variety of settings, with a greater availability of practicum and internship experiences in these settings. For example, Knight and Sayegh (2011: 238) suggest that religious institutions and prisons are emerging areas of practice for psychologists who are interested in working with older adults with serious mental health problems. Canadian researchers have begun developing interventions for homeless or marginally housed older people, many of whom have long-standing mental health issues (Ploeg et al. 2008). It is these groups that often experience the greatest barriers to mental healthcare.

In addition to broadening the range of training settings, attracting trainees who are multilingual would enhance the provision of mental health services to ethnic minority older persons. Training in telehealth interventions has tremendous potential to reach future cohorts of increasingly technologically sophisticated older adults, including those living in rural environments and isolated seniors. Perhaps most importantly, there needs to be an increased emphasis on how to address systemic barriers to mental healthcare for older adults and how to advocate for them. Karel et al. (2012b) provide several good examples of ageing policy and practice areas where psychologists have simply not been at the table. Learning how to be at the table and have a voice to affect broader change is an important skill that should be integrated into training curricula in clinical geropsychology.

Finally, overcoming barriers to implementing evidence-based treatments with older adults is an ongoing challenge. Evidence-based assessments and treatments are not uniformly embraced by all individuals and professions that work within systems of care for older adults. Even in environments that support evidence-based practice, there remains the question of how best to maintain fidelity while, at the same time, being flexible and adapting it to the context in which it is being delivered. Psychologists have been at the forefront of developing evidence-based practices, but less active in the area of knowledge translation. On a hopeful note, as psychologists become increasingly integrated into a variety of settings that serve older adults, their familiarity with these contexts will be highly beneficial in facilitating and promoting knowledge uptake of evidence-based practice.

Key References and Sources for Further Reading

Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., et al. (2004). ‘Improving Access to Geriatric Mental Health Services: A Randomized Trial Comparing Treatment Engagement with Integrated versus Enhanced Referral Care for Depression, Anxiety, and At-risk Alcohol Use’. American Journal of Psychiatry 161(8): 1455–1462.Find this resource:

Eli, K. (2006). ‘Depression Care for the Elderly: Reducing Barriers to Evidence-based Practice’. Home Health Care Services Quarterly 25(1–2): 115–148.Find this resource:

Hwang, W., Myers, H. F., Abe-Kim, J., and Ting, J. Y. (2008). ‘A Conceptual Paradigm for Understanding Culture’s Impact on Mental Health: The Cultural Influences on Mental Health (CIMH) Model’. Clinical Psychology Review 28: 211–227.Find this resource:

Jameson, J. P. and Blank, M. B. (2007). ‘The Role of Clinical Psychology In Rural Mental Health Services: Defining Problems and Developing Solutions’. Clinical Psychology: Science and Practice 14(3): 283–283.Find this resource:

Jorm, A. J. (2012). ‘Mental Health Literacy: Empowering the Community to Take Action for Better Mental Health’. American Psychologist 67(3): 231–243.Find this resource:

(p. 965) Moak, G. S. (2011). ‘Treatment of Late-life Mental Disorders in Primary Care: We Can Do a Better Job’. Journal of Aging and Social Policy 23(3): 274–285.Find this resource:

Nyunt, M. S. Z., Ko, S. M., Kumar, R., Fones, C., and Ng, T. P. (2009). ‘Improving Treatment Access and Primary Care Referrals for Depression in a National Community-based Outreach Programme for the Elderly’. International Journal of Geriatric Psychiatry 24(11): 1267–1276.Find this resource:

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