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Service provision for older people with mental health problems in a rural area of Australia a
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Eimear Muir-Cochrane , Deb O’Kane , Pat Barkway , Candice Oster & Jeffrey Fuller a
Faculty of Health Sciences, School of Nursing and Midwifery, Flinders University, Adelaide, Australia Published online: 05 Feb 2014.
Click for updates To cite this article: Eimear Muir-Cochrane, Deb O’Kane, Pat Barkway, Candice Oster & Jeffrey Fuller (2014) Service provision for older people with mental health problems in a rural area of Australia, Aging & Mental Health, 18:6, 759-766, DOI: 10.1080/13607863.2013.878307 To link to this article: http://dx.doi.org/10.1080/13607863.2013.878307
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Aging & Mental Health, 2014 Vol. 18, No. 6, 759–766, http://dx.doi.org/10.1080/13607863.2013.878307
Service provision for older people with mental health problems in a rural area of Australia Eimear Muir-Cochrane*, Deb O’Kane, Pat Barkway, Candice Oster and Jeffrey Fuller Faculty of Health Sciences, School of Nursing and Midwifery, Flinders University, Adelaide, Australia
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(Received 13 August 2013; accepted 12 December 2013) Objectives: Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia. Method: Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data. Results: Two main themes were identified: ‘Recognising the Problem’ and ‘Service Availability and Access’. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region. Conclusion: This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people. Keywords: mental health; older people; barriers; rural; interviews
Introduction Mental illness is a serious issue affecting older people (aged 65 and older). Older people may develop mental health problems in late life (e.g. dementia, late onset schizophrenia or depression and anxiety) or they may be growing older with a mental illness developed earlier in life (Royal Australian & New Zealand College of Psychiatrists, 2010). Reported rates of mental health problems in older populations vary, depending on the context. For example, a recent review of the literature by the Australian National Ageing Research Institute (2009) found that rates of depression in older people range from 6% to 20% in community dwellings, up to 50% in people living in residential aged care and 48% in a hospital sample. Another Australian study found that approximately 5% of people in nursing homes had schizophrenia or a paranoid disorder (Australian Department of Health and Family Services, 1997). In the emergency department context approximately 60% of patients aged over 65 are reported to have mental health problems (Goldberg et al., 2012). Mental health problems are experienced across the lifespan, but for older people, these problems are often associated with co-morbid physical conditions and disability, creating added distress for older people and their carers and increased complexity in health care needs (Sirey et al., 2008). In particular, concerns have been raised about high levels of unmet need for mental health services in older people (Crabb & Hunsley, 2006; Gureje, Kola, & Afolabi 2007; Sirey et al., 2008), and delays to first seeking treatment (Thompson, Issakidis, & Hunt, 2008). An analysis of the data relating to older people from the 1997 Australian
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
National Health and Wellbeing Survey found that only 25.8% of older people with one mental disorder and 31% with three or more disorders had consulted a mental health professional in the past 12 months (Troller, Anderson, Sachdev, Brodaty, & Andrews, 2007). There are a number of possible reasons for the unmet mental health care needs of older people. It has been reported that older adults (aged 65 and over) are less likely to perceive a need for mental health services than younger adults (18–29) or middle-aged adults (30–64) (Klap, Unroe, & Unutzer, 2003). This may be due to poorer mental health literacy in older adults (Farrer, Leach, Griffiths, Chirstensen, & Jorm, 2008) or because of an increased likelihood of older adults holding a belief in self-reliance than younger adults (Wetherell et al., 2004). Perceived stigma may lead to older people failing to seek help for mental health problems; however, studies on stigma have found mixed results; some have found higher mental health related stigma among older people, some among younger people and others with no age effects (Griffiths, Christensen, & Jorm, 2008; Pettigrew, Donovan, Pescud, Boldy, & Newton, 2010; Prins, Verhaak, Bensing, & van der Meer, 2008). Service inadequacies and gaps in services may also result in unmet mental health care needs (Knight & Sayegh, 2011). For example, elderly patients are reportedly referred less frequently to psychiatrists than younger people with the same symptoms (Cuddy & Fiske, 2002), although the reasons for this are unclear. There is also a lack of professionals specialised in mental health problems in later life (National Ageing Research Institute, 2009).
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These issues are magnified in rural populations. In 2011, 3.1 million people in Australia were aged 65 years and over, with 35% of older people living outside of major Australian cities (populations of less than 100,000) (Australian Bureau of Statistics, 2013). There is little information on the percentage of rural older Australians with mental health problems; however, overseas literature has reported rates of depression in rural older adults ranging from 23.3% in an American study (Bocker, Glasser, Nielson, & Weidenbacher-Hoper, 2012) to 39% in a Saudi Arabian study (Al-Shammari & Al-Subaie, 1999). Australian literature has reported the disadvantages of rural ageing associated with ‘rural poverty and economic stress, the challenges of farmer ageing and succession, climatic stress and natural disasters’ (Warburton, Cowan, & Bathgate, 2013, p. 10). Access to health services, infrastructure and adequately trained professionals is a significant issue in rural areas (Bocker et al., 2012). A survey of the size and distribution of publicly funded aged psychiatry services in Australia and New Zealand found that these services are inequitably distributed, generally based in capital cities with limited coverage in regional and rural areas (O’Connor & Melding, 2006). The impact of stoicism and self-efficacy on help-seeking for mental health problems may also be more significant in rural areas, with these qualities described as ‘agrarian values’ that affect helpseeking behaviour by rural residents (Judd et al., 2006). Stigma, too, may be more of an issue in rural areas. For example, Parr and Philo’s (2003) study of rural mental health found that ‘many users [of mental health services] and formal and informal carers return again and again to gossip networks and to the social proximity and visibility that characterizes social life in this part of the world’ (p. 484). Lack of adequate mental health care for older people can lead to health deterioration, more frequent and longer acute hospitalisation, compounded treatment for co-morbid physical health conditions and earlier admission to residential care facilities (Crabb & Hunsley, 2006; Thompson et al., 2008). There is little understanding of service needs and gaps for older people with mental health problems living in rural areas. This study aimed to explore the views of health and social care providers of the barriers to effective mental health care for older people in a rural region.
Method Participants The study was conducted in a rural region of Australia (population 46,354 of which 26.4% are aged over 65). The region is typical of many rural locations that are within 100 km of metropolitan centres, but still face difficulties in access to services, coordination and follow up. A member of a local taskforce concerned with positive ageing in the region (who was not a member of the research team) made contact with 16 local government and non-government health and social care agencies
providing services to older people. Agencies were asked to suggest potential participants for the study, who were contacted by the researchers and invited to take part in an interview. Purposive sampling was used to recruit participants, with the aim of recruiting the most senior clinical service provider who would know about services to older people in the region and be willing to be interviewed. Nineteen key informants from 13 organisations participated in the study (see Table 1 for a description of participating organisations). The participants occupied a range of roles within these organisations, including: managers of residential and community aged care services; coordinators of programmes and care packages; nurses; occupational therapists; social workers; counsellors; and mental health clinicians specialising in the care of older adults.
Ethical considerations Approval for the study was obtained from University and health services’ human research ethics committees. Participants were informed that they were under no obligation to participate, that they could choose not to participate at any point without penalty, and that their anonymity and confidentiality would be maintained.
Data collection Eighteen interviews were conducted with the 19 key informants (a joint interview was conducted with two participants). The participants were asked to discuss one or two clients aged 65 or older who have mental health Table 1. Participating organisations. Organisation type
Organisation function
Providing retirement and Residential and residential options, community aged domestic, personal and care – not-fornursing care in the profit home, respite and short-term transition services Providing retirement and Residential and residential options, community aged domestic, personal and care – private nursing care in the home, respite and short-term transition services Government health Providing general health service care and specialist organisations mental health care Local government Providing health and wellorganisations being programmes, home and community support and social opportunities for people who are isolated due to ageing, illness or disability Carer support Providing support and organisations respite to carers
Number of organisations 4
1
5 2
1
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problems, focusing in particular on: the nature of the problem; the services they access; gaps in services. They were also asked about groups of older people who are well served and groups who may miss out on mental health services, strengths and weaknesses of local service systems and the capacity of local services to meet the mental health care needs of older people. Seventeen face-to-face interviews and one telephone interview were conducted between March and May 2013. The average duration of the interviews was 30 minutes. Analysis The interviews were audio-taped and transcribed verbatim. We used a framework analysis approach to thematically analyse the data. Framework analysis is a qualitative method of analysis that is specifically suited to applied research that has specific questions, a limited timeframe, a pre-designed sample and a-priori issues that are to be explored (Strivastava & Thomson, 2009). Framework analysis involves a five-step process: familiarisation with the interviews and transcripts to gain an overview of the data and note any key ideas and recurrent themes; identifying a thematic framework, using both a priori and new themes arising from the data; indexing, where portions or sections of the data that correspond to a particular theme are identified; charting, where indexed pieces of data are arranged in charts of the themes; and mapping and interpretation, which involves analysis of the key characteristics as laid out in the charts. Two of the authors read through the transcripts and undertook separate analyses to identify initial codes (e.g. stigma, stoicism, referral, availability of services, gatekeeping). These were then amalgamated into themes. All authors were involved in discussing and finalising the analysis. Results The analysis focused on the identified barriers to the provision of mental health services for older people in the region. Two main themes were identified: ‘Recognising the Problem’ and ‘Service Availability and Access’. The themes are discussed in detail in the following sections. Only broad information about the service type (general health, mental health, aged care, community service) is provided alongside participants’ quotations in order to ensure their anonymity. Recognising the problem One of the main barriers identified by the participants was the ability of older people, their carers and health professionals to recognise the presence of a mental health problem in the first place. Two issues were identified; the first relates to the attitudes of older people while the second relates to the attitudes of health professionals. In terms of older people’s attitudes, a major barrier was described as older people’s reluctance to admit they might have a mental health problem. Participants described older people’s reluctance to access mental
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health services such as counselling or assessment when it is offered. Participants felt that one reason for this reluctance is the perceived stigma of being labelled as having a mental health problem: . . . to be labelled as having a mental health issue is something that people don’t want to wear. (Community Service)
Some participants saw this as an issue of particular relevance to older people due to differences in generational understandings of mental health problems, while others saw stigma as a potential issue across the generations. Perceived stigma was described as especially pertinent in a small rural community where people’s lives are more visible: . . . it’s a small community and small communities talk. I think there’s that uncomfortable ease and that stigma around a mental health issue. (Aged Care)
Stoicism was described as another attitudinal barrier to older people not seeking mental health care. Participants felt that older people, particularly older men, are less likely than younger people to admit they have a problem, viewing this as ‘a sign of weakness’ (Community Service). Furthermore, older people were described as refusing services because they see others as being more in need of the services than themselves: Sometimes, and I hear it so often, people will say, ‘there are people out there who need it more than me’. They don’t see themselves as needing a service and they always think that there’s somebody worse off than them. (Aged Care)
The final attitudinal barrier to older people accessing mental health care was a lack of trust. Participants noted that older people might feel that if they admit they have a problem, or that an existing problem has exacerbated, they may be institutionalised or subjected to frightening procedures. This may be because of stigmatised notions of how mental health problems are treated: [Older people] have that vision of ECT [Electroconvulsive Therapy] and other mental treatments from their youth . . . so I think that has a lot to do with it. (Aged Care)
This issue may be even greater for older people with previously diagnosed mental health problems whose past relationships with health professionals may lead to a lack of trust in the mental health professions. Participants also identified the attitudes of health professionals as having a role to play. They expressed general agreement that there is a tendency for health professionals to focus on physical illness in consultations with older people while ignoring or dismissing indications of, or a patient’s concerns about, mental health problems: So she went off to the doctor and saw not her own GP but somebody in the system [about a mental health problem].
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. . . so she rang me and she was quite distressed because he had basically said “well what do you want me to do, I can take your blood pressure, I can take your temperature”, so really dismissive. (Community Service)
This lack of understanding of the mental health needs of older people was also identified in relation to the needs of carers, where the focus is on the health of the person being cared for with little awareness of how the carer may be coping with his or her role. Participants also felt that mental health problems in older people in general are not well understood by health professionals, particularly problems that develop in later life as opposed to ongoing mental health problems diagnosed earlier in life. One issue is a tendency to view all mental health problems in older people as dementia related. Another issue is where symptoms of depression or other less severe mental health problems are interpreted as being a normal part of ageing: . . . so many of these needs that people have are wiped off as just being old age, you know, “it’s understandable that you’ll be having trouble sleeping because that just happens when you get old”. (Community Service)
This lack of awareness or understanding on the part of health professionals means that older people are not being referred to appropriate services.
Service availability and access In addition to the attitudes of older people and health professionals towards mental health problems, participants also identified service availability and access as a barrier to effective service provision. In other words, once older people and their health providers understand and accept the need for mental health services, there is still the issue of whether or not these services are available, appropriate and accessible. There were two perspectives on this: participants who stated that the services were simply not available and those who stated that the services were available but not accessed. Participants discussed the inadequacy of services to meet the mental health care needs of older people, particularly in terms of difficulties getting an appointment with local general practitioners (GPs) and mental health services. Specialist psychiatric services and acute mental health services for older people were also described as difficult to access, because they are not available locally and clients either have to travel to a metropolitan service or wait for health professionals to visit. While many participants identified a lack of services, others stated that services are available, but many of these are already at capacity; consequently any increased recognition of mental health problems in older people would most likely mean that services would not be available when needed: . . . the services are available, the services are there but they are already stretched, they’re already at capacity. (Mental Health)
As a result older people who are able to get a referral would have to go on a waiting list, providing a further barrier to effective service provision. There was also a perception among participants that services are generally set up to address physical illness, and that people with mental health problems miss out on available support and services. This is particularly the case with community support: I guess things are set up for physical . . . you’ve got a lot of physical things set up, rails and access, but in the mental health side of things you need a lot more support and I don’t think we do that well in terms of community support for mental health. (Mental Health)
Participants across all services expressed concern that the separation of physical and mental health in service provision was detrimental to older people and that a more integrated and holistic approach would better serve the needs of this population. This issue is further exacerbated by a perceived tendency of mental health services being clinically oriented, neglecting the broader needs of clients (e.g. for social support or in-home support): I think the region in general has limited services. It’s very much the services that are here are very, at the clinical end of services . . . I think in all of the way health services are structured the emphasis is so much on the clinical stuff. (Community Service)
In addition to a lack of availability of adequate services, barriers in accessing services were also identified. This included a lack of knowledge about what services are available and where to access them, both on the part of older people and their families as well as health professionals and services providers: I would assume there is probably a large group of people out there who aren’t accessing services; again because they just don’t know about them, they just don’t know where to start, where to look. They wouldn’t know. (Aged Care)
Barriers associated with transport were also discussed; particularly the difficulty for frail older people in having to travel long distances to access services when they have no personal transport and when there is no public transport. Another access barrier was the lack of effective collaboration between health care organisations, in particular the lack of formal processes for this. A range of organisations were identified as being involved in the provision of care to older people in the region, including residential and community aged care, general health and specialist mental health services, local government organisations and carer support services. Older people may also interact with services outside of this region such as specialist geriatric psychiatric services, acute inpatient mental health care and services specific to particular diagnoses such as dementia or drug and alcohol services. The participants described regular team meetings between local aged care and community services focused around the physical and
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social needs of older people, with mental health services being on the periphery of these relationships. Some participants identified the difficulties with establishing effective collaborative relationships between organisations as resulting from the separation of physical and mental health care, discussed earlier. Mental health services, both within and outside of the region, were generally accessed through referrals and phone calls for advice. Referral was the most commonly identified form of collaboration, but this was described as inefficient as it has to be done through the GP with other services unable to ‘facilitate that directly’ (Mental Health): I think just the process is hard, the system, because you have to navigate a system . . . you have to go via the GP and then they have to refer, and often there’s time that’s going to take with paperwork, this service or that service and get this referral or that referral. . . . It’s a system that people find hard to navigate. (Mental Health)
Having to go through GPs to access services, rather than refer clients directly, was particularly frustrating when GPs did not respond to recommendations from other service providers for referral: I mean the GP service here is the hub of care and I have sent a letter to her GP just explaining, outlining that I have a few concerns, which I’ve had no response on. (Aged Care)
Difficulties were also described with the use of referral pathways due to frequent changes of staff with subsequent loss of knowledge and understanding about these processes: There are formal [referral] pathways but it’s in the working of it, we struggle to maintain it because the minute there is a change in staff on the ground level then that knowledge doesn’t necessarily get passed on. (Mental Health)
Effective referral was often reliant on personal relationships rather than formal pathways to expedite the process. Competition for resources was identified as a barrier to collaboration because instead of working together to provide the most effective and appropriate services for older people, organisations find themselves working against each other as they try to gain their piece of the ‘funded pie’ (Mental Health): Everyone’s trying to compete for a small amount or pool of resources. (Mental Health)
Participants discussed how physical ailments, such as falls or diabetes, often have clear, tangible outcomes, such as reduced falls or better diabetes management after a short assessment and intervention; mental health assessment, however, takes longer and outcomes are not always clear. With funding often allocated on the basis of outcomes, people with mental health problems frequently miss out:
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For example, the falls, that’s got a lot of research base, that’s got set exercises that work, you’ve got set things that you can do, you’ve then got set things that you can give to the GP, you can say “we do falls prevention” and then the doctor says “fall, we’ll refer to there”. . . . mental health is really hard . . . we can’t prove our outcomes. (Mental Health)
Further exacerbating the barriers to effective collaboration is gatekeeping, which occurs where service providers refuse to accept certain people due to the compartmentalisation of services around specific diagnostic criteria. This means that people with complex, interconnecting physical and mental health problems end up being shunted between services as they try to determine who is best to help with different aspects of the problems. This was also described as being difficult when people have mental health problems and dementia: . . . people that do have a diagnosis of dementia are not readily up-taken by mental health services. If you’ve got dementia then you’re over there, if you’ve got dementia and depression well it’s a little harder to get that taken up. (General Health)
Gatekeeping also occurs where community aged care services and residential aged care providers may refuse to accept a person who has a history of aggression, or a service provider refuses a client who has a mental health problem and is likely to bring in less funding than another client with access to a wider range of funding for physical health supports and services. Participants identified that the consequences of delays in access to mental health services and inadequate services provision could be severe. This includes the need for crisis management, hospitalisation and early admission to residential care for conditions that could have been more easily managed had they been identified and addressed earlier.
Discussion The purpose of this study was to explore the barriers to effective mental health care for older people in a rural region in Australia. Overall, the participants viewed care provision to older people with mental health problems as inadequate and ineffective. They identified attitudinal and service-based barriers – what Pepin, Segal, and Coolidge (2009) call intrinsic barriers and extrinsic barriers. Participants’ discussions of intrinsic barriers, both those of older people and health professionals, reflect similar findings on stigmatisation, stoicism and denial as reasons for older people failing to seek and access support for mental health problems (Pepin et al., 2009; Pettigrew et al., 2010; Prins et al., 2008; Wetherell et al., 2004). Similarly the variation in participants’ views of whether stigma is an issue that disproportionately affects older people, or exists across generations, is reflected in other studies (Griffiths et al., 2008; Klap et al., 2003; Pettigrew et al., 2010). Connected to the issue of stigma is that of trust, where older people were identified as having stigmatised ideas of what treatment for a mental health problem
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means (e.g. electroconvulsive therapy [ECT] or institutionalisation). Further, trust was identified as a potential barrier for older people with previously diagnosed mental health problems whose experiences may lead them to be suspicious of the intentions of health professionals. The participants also discussed health professionals’ assumptions about older people and mental health, and the possible impact of ageist notions on the likelihood that older people will be referred to services. According to the National Ageing Research Institute (2009), ageist behaviour is common in medical settings, including a tendency to patronise and listen less to the views of older patients, order fewer diagnostic tests and attribute symptoms to age, rather than treatable conditions. A review by the UK Centre for Policy on Ageing (2009) found that GPs often see depression as ‘just a part of ageing’ (p. 70). Mitford, Reay, McCabe, Paxton, and Turkington (2010) found that older people with first-episode psychosis are often denied access to services, guidelines and funding that are readily made available to younger people. Researchers and commentators have referred to this as the ‘double stigmatisation of older people with mental health disorders’ (Mitford, et al., 2010, p. 1117) due to both ageism and stigma towards mental illness, which limits access to mental health services for older people (Centre for Policy on Ageing, 2009). Participants in our study also discussed extrinsic barriers to mental health care for older people in the region. These barriers are similar to those reported by health services in an Australian survey of mental health service delivery to older people in New South Wales (Draper et al., 2003). In this research Draper et al. (2003) explored relationships between aged care services, adult mental health services and mental health services for older people and found that services were affected by lack of access to specialist staff, resource limitations and inadequate support and liaison between service types. Other studies of gaps in mental health care for older people have identified similar barriers (Centre for Policy on Ageing, 2009; Crotty, Henderson, Martinez, & Fuller, 2013; Knight & Sayegh, 2011). A major barrier identified by participants that has not been previously reported was the perception that the focus of services is on physical health and clinical aspects of mental health care. Participants reported that physical and mental health were addressed as separate issues for the client, with little understanding of the holistic and interconnected nature of the older person’s physical and mental health. This interconnection has been explored in the literature in relation to the general population (Sturgeon, 2007). For example, the World Federation for Mental Health (2004) notes the co-occurrence of physical illness with mental health problems, as well as the frequency with which people with severe and persistent mental illnesses experience a variety of physical disorders and complications. The need for holistic care is likely to be even greater for older people with complex health problems and multiple physical and mental health care needs.
Linked with this is the concern that governmentfunded community support packages are geared towards addressing the needs of clients with physical health problems, and are inadequate to address the needs of older people with mental health problems. For example, Kellett, Shugrue, Grunman, and Robinson (2010) found higher levels of unmet need for agency-based homemaker services and transportation in older people with mental health problems in the USA compared to people with other disabilities. This is of particular concern given that older people with mental health problems experience increased social isolation (Kellett et al., 2010), yet social support and engagement is vital in facilitating access to health services for older people (McCracken et al., 2006). It appears from our study that a wide range of organisations are involved in the provision of care to older people with mental health problems in the region. This array of services is similar to the situation in the United States as discussed by Knight and Sayegh (2011). They identified a multi-system, multi-level and diagnosis specific network of systems of health care available for older people, and into which older people with mental health problems may present due to the complexity of physical and mental health problems and co-morbidity. Participants in our study reported some form of loose collaborative relationship between services; however, they also reported a lack of involvement of mental health services, little knowledge about available services, inadequate referral processes, competition for funding, gatekeeping and a lack of formal collaborative relationships – what Knight and Sayegh call ‘loosely coupled and competing systems of care’ (2011, p. 236). Similar barriers were reported in Crotty et al.’s (2013) survey of external agency views of barriers to collaboration in mental health services for older people. The consequences of this system of service provision was reported to be older people with mental health care needs falling through the gaps between available services, a ‘common conceptualisation of the shortcomings of the mental health care system for older adults’ (Knight & Sayegh, 2011, p. 236). It is clear from the research literature that older people with mental health problems face many of the barriers also identified by our study participants irrespective of where they live; however, there were specific issues associated with living in a rural area that impact on access to mental health services, such as the lack of locally available specialist psychogeriatric and acute inpatient mental health services. The inequitable distribution of publicly funded aged psychiatry services in Australia has been reported elsewhere, with these services generally located in capital cities with limited coverage in regional and rural areas (O’Connor & Melding, 2006). This means that the difficulties that many older people may face with accessing mental health services is further exacerbated by the long distances when they have to travel to metropolitan locations, and when there is a lack of travel resources to do so (Bocker et al., 2012). In addition, long waiting times, lack of after-hours services and poor referral protocols can also be exacerbated in rural areas. For example, Pierce and Brewer (2012) found that prolonged waiting
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times and GP gatekeeping were barriers to the effectiveness of an Australian government funded counselling programme for people in rural areas.
Conclusions This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. More specifically, the study identifies the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people. The study also offers new information and understanding of barriers to mental health care for older people, in particular the impact of the separation of physical and mental health care and the inadequacy of Australian government funded community support packages to meet the needs of older people with mental health problems. The study also provides new insight into the impact of living in a rural region on unmet mental health care needs for older people. Limitations This is a qualitative, exploratory study and as such is limited in terms of generalisability. Additional research needs to be done exploring the extent to which these findings are applicable more generally in rural areas, and in particular in other countries given the differences in health systems. Research exploring older people’s perspectives of barriers to mental health care in rural areas is also needed. References Al-Shammari, S.A., & Al-Subaie, A. (1999). Prevalence and correlates of depression among Saudi elderly. International Journal of Geriatric Psychiatry, 14, 739–747. Australian Bureau of Statistics. (2013). Reflecting a nation: Stories from the 2011 census. Canberra: Author. Australian Department of Health and Family Services. (1997). Care needs of people with dementia and challenging behaviour living in residential facilities. Canberra: Commonwealth of Australia. Bocker, E., Glasser, M., Nielson, K., & Weidenbacher-Hoper, V. (2012). Rural older adults’ mental health: Status and challenges in care delivery. Rural and Remote Health, 12, 2199. Centre for Policy on Ageing. (2009). Ageism and age discrimination in mental health care in the United Kingdom. London: Author. Crabb, R., & Hunsley, J. (2006). Utilization of mental health care services among older adults with depression. Journal of Clinical Psychology, 62(3), 299–312. Crotty, M.M., Henderson, J., Martinez, L., & Fuller, J.D. (2013). Barriers to collaboration in mental health services for older people: External agency views. Australian Journal of Primary Health. Advance online publication. doi:10.1071/ PY12144 Cuddy, A.J.C., & Fiske, S.T. (2002). Doddering but dear: Process, content and function of stereotyping of older persons. In T.D. Nelson (Ed.), Ageism (pp. 3–26). Cambridge: MIT Press. Draper, B., Jochelson, T., Kitching, D., Snowdon, J., Brodaty, H., & Russell, B. (2003). Mental health service delivery to older people in New South Wales: Perceptions of aged care,
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adult mental health and mental health services for older people. Australian and New Zealand Journal of Psychiatry, 37, 735–740. Farrer, L., Leach, L., Griffiths, K.M., Chirstensen, H., & Jorm, A.F. (2008). Age differences in mental health literacy. BMC Public Health, 8, 125. doi:10.1186/1471-2458-8-125 Goldberg, S.E., Whittamore, K.H., Harwood, R.H., Bradshaw, L.E., Gladman, J.R.F., & Jones, R.G. (2012). The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age and Ageing, 41, 80–86. Griffiths, K.M., Christensen, H., & Jorm, A.F. (2008). Predictors of depression stigma. BMC Psychiatry, 8, 25. doi: 10.1186/ 1471-244X-8-25 Gureje, O., Kola, L., & Afolabi, E. (2007). Epidemiology of major depressive disorder in elderly Nigerians in the Ibadan Study of Ageing: A community-based survey. Lancet, 370, 957–964. Judd, F., Jackson, H., Komiti, A., Murray, G., Fraser, C., Grieve, A., & Gomez, R. (2006). Help-seeking by rural residents for mental health problems: The importance of agrarian values. Australian and New Zealand Journal of Psychiatry, 40, 769–776. Kellett, K., Shugrue, N., Grunman, C., & Robinson, J. (2010). Mental illness and long term care needs: Identifying the long term care needs of older and middle aged adults with mental illness. International Review of Modern Sociology, 36(2), 143–168. Klap, R., Unroe, K.T., & Unutzer, J. (2003). Caring for mental illness in the United States: A focus on older adults. American Journal of Geriatric Psychology, 11(5), 517–524. Knight, B.G., & Sayegh, P. (2011). Mental health and aging in the 21st century. Journal of Aging and Social Policy, 23(3), 228–243. McCracken, C., Dalgard, O.S., Ayuso-Mateos, J.L., Casey, P., Wilkinson, G., Lehtinen, V., & Dowrick, C. (2006). Health service use by adults with depression: Community survey in five European Countries, evidence from the ODIN study. British Journal of Psychiatry, 189, 161–167. Mitford, E., Reay, R., McCabe, K., Paxton, R., & Turkington, D. (2010). Ageism in first episode psychosis. International Journal of Geriatric Psychiatry, 25, 1112–1118. National Ageing Research Institute. (2009). Depression in older age: A scoping study. Melbourne: Author. O’Connor, D., & Melding, P. (2006). A survey of publicly funded aged psychiatry services in Australia and New Zealand. Australian and New Zealand Journal of Psychiatry, 40, 368–373. Parr, H., & Philo, C. (2003). Rural mental health and social geographies of caring. Social and Cultural Geography, 4(4), 471–488. Pepin, R., Segal, D.L., & Coolidge, F.L. (2009). Intrinsic and extrinsic barriers to mental health care among communitydwelling younger and older adults. Aging & Mental Health, 13(5), 769–777. Pettigrew, D., Donovan, R., Pescud, M., Boldy, D., & Newton, R. (2010). Mature adults’ attitudes to mental health service utilisation. Australian Psychologist, 45(2), 141–150. Pierce, D., & Brewer, C. (2012). Factors promoting use of mental health services in a rural area of Australia. Community Medicine and Health Education, 2, 11–17. Prins, M.A., Verhaak, P.F.M., Bensing, J.M., & van der Meer, K. (2008). Health beliefs and perceived need for mental health care of anxiety and depression: The patients’ perspective explored. Clinical Psychology Review, 18, 1038–1058. Royal Australian and New Zealand College of Psychiatrists. (2010). Caring for older Australians: Submission to the Productivity Commission public inquiry into Australia’s aged care system. Melbourne: Author.
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Sirey, J.A., Bruce, M.L., Carpenter, M., Booker, D., Carrington Reid, M., Newell, K.-A., & Alexopoulos, G.S. (2008). Depressive symptoms and suicidal ideation among older adults receiving home delivered meals. International Journal of Geriatric Psychiatry, 23, 1306–1311. Strivastava, A., & Thomson, S.B. (2009). Framework analysis: A qualitative methodology for applied policy research. Journal of Administration Governance, 4(2), 72–79. Sturgeon, S. (2007). Promoting mental health as an essential aspect of health promotion. Health Promotion International, 21(S1), 36–41. Thompson, A., Issakidis, C., & Hunt, C. (2008). Delay to seek treatment for anxiety and mood disorders in an Australian clinical sample. Behaviour Change, 25(2), 71–84. Troller, J.N., Anderson, T.M., Sachdev, P.S., Brodaty, H., & Andrews, G. (2007). Prevalence of mental disorders in the
elderly: The Australian National Mental Health and WellBeing Survey. American Journal of Geriatric Psychiatry, 15(6), 455–466. Warburton, J., Cowan, C., & Bathgate, T. (2013). Building social capital among rural, older Australians through information and communication technologies: A review article. Australasian Journal on Ageing, 32(1), 8–14. Wetherell, J.L., Kaplan, R.M., Kallenberg, G., Dresselhaus, T.R., Sieber, W.J., & Lang, A.J. (2004). Mental health treatment preferences of older and younger primary care patients. The International Journal of Psychiatry in Medicine, 34(3), 219–233. World Federation for Mental Health. (2004). World Mental Health Day. The relationship between physical and mental health: Co-occurring disorders. Alexandria: Author.
Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Service provision for older people with mental health problems in a rural area of Australia a
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Eimear Muir-Cochrane , Deb O’Kane , Pat Barkway , Candice Oster & Jeffrey Fuller a
Faculty of Health Sciences, School of Nursing and Midwifery, Flinders University, Adelaide, Australia Published online: 05 Feb 2014.
Click for updates To cite this article: Eimear Muir-Cochrane, Deb O’Kane, Pat Barkway, Candice Oster & Jeffrey Fuller (2014) Service provision for older people with mental health problems in a rural area of Australia, Aging & Mental Health, 18:6, 759-766, DOI: 10.1080/13607863.2013.878307 To link to this article: http://dx.doi.org/10.1080/13607863.2013.878307
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Aging & Mental Health, 2014 Vol. 18, No. 6, 759–766, http://dx.doi.org/10.1080/13607863.2013.878307
Service provision for older people with mental health problems in a rural area of Australia Eimear Muir-Cochrane*, Deb O’Kane, Pat Barkway, Candice Oster and Jeffrey Fuller Faculty of Health Sciences, School of Nursing and Midwifery, Flinders University, Adelaide, Australia
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(Received 13 August 2013; accepted 12 December 2013) Objectives: Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia. Method: Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data. Results: Two main themes were identified: ‘Recognising the Problem’ and ‘Service Availability and Access’. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region. Conclusion: This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people. Keywords: mental health; older people; barriers; rural; interviews
Introduction Mental illness is a serious issue affecting older people (aged 65 and older). Older people may develop mental health problems in late life (e.g. dementia, late onset schizophrenia or depression and anxiety) or they may be growing older with a mental illness developed earlier in life (Royal Australian & New Zealand College of Psychiatrists, 2010). Reported rates of mental health problems in older populations vary, depending on the context. For example, a recent review of the literature by the Australian National Ageing Research Institute (2009) found that rates of depression in older people range from 6% to 20% in community dwellings, up to 50% in people living in residential aged care and 48% in a hospital sample. Another Australian study found that approximately 5% of people in nursing homes had schizophrenia or a paranoid disorder (Australian Department of Health and Family Services, 1997). In the emergency department context approximately 60% of patients aged over 65 are reported to have mental health problems (Goldberg et al., 2012). Mental health problems are experienced across the lifespan, but for older people, these problems are often associated with co-morbid physical conditions and disability, creating added distress for older people and their carers and increased complexity in health care needs (Sirey et al., 2008). In particular, concerns have been raised about high levels of unmet need for mental health services in older people (Crabb & Hunsley, 2006; Gureje, Kola, & Afolabi 2007; Sirey et al., 2008), and delays to first seeking treatment (Thompson, Issakidis, & Hunt, 2008). An analysis of the data relating to older people from the 1997 Australian
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
National Health and Wellbeing Survey found that only 25.8% of older people with one mental disorder and 31% with three or more disorders had consulted a mental health professional in the past 12 months (Troller, Anderson, Sachdev, Brodaty, & Andrews, 2007). There are a number of possible reasons for the unmet mental health care needs of older people. It has been reported that older adults (aged 65 and over) are less likely to perceive a need for mental health services than younger adults (18–29) or middle-aged adults (30–64) (Klap, Unroe, & Unutzer, 2003). This may be due to poorer mental health literacy in older adults (Farrer, Leach, Griffiths, Chirstensen, & Jorm, 2008) or because of an increased likelihood of older adults holding a belief in self-reliance than younger adults (Wetherell et al., 2004). Perceived stigma may lead to older people failing to seek help for mental health problems; however, studies on stigma have found mixed results; some have found higher mental health related stigma among older people, some among younger people and others with no age effects (Griffiths, Christensen, & Jorm, 2008; Pettigrew, Donovan, Pescud, Boldy, & Newton, 2010; Prins, Verhaak, Bensing, & van der Meer, 2008). Service inadequacies and gaps in services may also result in unmet mental health care needs (Knight & Sayegh, 2011). For example, elderly patients are reportedly referred less frequently to psychiatrists than younger people with the same symptoms (Cuddy & Fiske, 2002), although the reasons for this are unclear. There is also a lack of professionals specialised in mental health problems in later life (National Ageing Research Institute, 2009).
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These issues are magnified in rural populations. In 2011, 3.1 million people in Australia were aged 65 years and over, with 35% of older people living outside of major Australian cities (populations of less than 100,000) (Australian Bureau of Statistics, 2013). There is little information on the percentage of rural older Australians with mental health problems; however, overseas literature has reported rates of depression in rural older adults ranging from 23.3% in an American study (Bocker, Glasser, Nielson, & Weidenbacher-Hoper, 2012) to 39% in a Saudi Arabian study (Al-Shammari & Al-Subaie, 1999). Australian literature has reported the disadvantages of rural ageing associated with ‘rural poverty and economic stress, the challenges of farmer ageing and succession, climatic stress and natural disasters’ (Warburton, Cowan, & Bathgate, 2013, p. 10). Access to health services, infrastructure and adequately trained professionals is a significant issue in rural areas (Bocker et al., 2012). A survey of the size and distribution of publicly funded aged psychiatry services in Australia and New Zealand found that these services are inequitably distributed, generally based in capital cities with limited coverage in regional and rural areas (O’Connor & Melding, 2006). The impact of stoicism and self-efficacy on help-seeking for mental health problems may also be more significant in rural areas, with these qualities described as ‘agrarian values’ that affect helpseeking behaviour by rural residents (Judd et al., 2006). Stigma, too, may be more of an issue in rural areas. For example, Parr and Philo’s (2003) study of rural mental health found that ‘many users [of mental health services] and formal and informal carers return again and again to gossip networks and to the social proximity and visibility that characterizes social life in this part of the world’ (p. 484). Lack of adequate mental health care for older people can lead to health deterioration, more frequent and longer acute hospitalisation, compounded treatment for co-morbid physical health conditions and earlier admission to residential care facilities (Crabb & Hunsley, 2006; Thompson et al., 2008). There is little understanding of service needs and gaps for older people with mental health problems living in rural areas. This study aimed to explore the views of health and social care providers of the barriers to effective mental health care for older people in a rural region.
Method Participants The study was conducted in a rural region of Australia (population 46,354 of which 26.4% are aged over 65). The region is typical of many rural locations that are within 100 km of metropolitan centres, but still face difficulties in access to services, coordination and follow up. A member of a local taskforce concerned with positive ageing in the region (who was not a member of the research team) made contact with 16 local government and non-government health and social care agencies
providing services to older people. Agencies were asked to suggest potential participants for the study, who were contacted by the researchers and invited to take part in an interview. Purposive sampling was used to recruit participants, with the aim of recruiting the most senior clinical service provider who would know about services to older people in the region and be willing to be interviewed. Nineteen key informants from 13 organisations participated in the study (see Table 1 for a description of participating organisations). The participants occupied a range of roles within these organisations, including: managers of residential and community aged care services; coordinators of programmes and care packages; nurses; occupational therapists; social workers; counsellors; and mental health clinicians specialising in the care of older adults.
Ethical considerations Approval for the study was obtained from University and health services’ human research ethics committees. Participants were informed that they were under no obligation to participate, that they could choose not to participate at any point without penalty, and that their anonymity and confidentiality would be maintained.
Data collection Eighteen interviews were conducted with the 19 key informants (a joint interview was conducted with two participants). The participants were asked to discuss one or two clients aged 65 or older who have mental health Table 1. Participating organisations. Organisation type
Organisation function
Providing retirement and Residential and residential options, community aged domestic, personal and care – not-fornursing care in the profit home, respite and short-term transition services Providing retirement and Residential and residential options, community aged domestic, personal and care – private nursing care in the home, respite and short-term transition services Government health Providing general health service care and specialist organisations mental health care Local government Providing health and wellorganisations being programmes, home and community support and social opportunities for people who are isolated due to ageing, illness or disability Carer support Providing support and organisations respite to carers
Number of organisations 4
1
5 2
1
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problems, focusing in particular on: the nature of the problem; the services they access; gaps in services. They were also asked about groups of older people who are well served and groups who may miss out on mental health services, strengths and weaknesses of local service systems and the capacity of local services to meet the mental health care needs of older people. Seventeen face-to-face interviews and one telephone interview were conducted between March and May 2013. The average duration of the interviews was 30 minutes. Analysis The interviews were audio-taped and transcribed verbatim. We used a framework analysis approach to thematically analyse the data. Framework analysis is a qualitative method of analysis that is specifically suited to applied research that has specific questions, a limited timeframe, a pre-designed sample and a-priori issues that are to be explored (Strivastava & Thomson, 2009). Framework analysis involves a five-step process: familiarisation with the interviews and transcripts to gain an overview of the data and note any key ideas and recurrent themes; identifying a thematic framework, using both a priori and new themes arising from the data; indexing, where portions or sections of the data that correspond to a particular theme are identified; charting, where indexed pieces of data are arranged in charts of the themes; and mapping and interpretation, which involves analysis of the key characteristics as laid out in the charts. Two of the authors read through the transcripts and undertook separate analyses to identify initial codes (e.g. stigma, stoicism, referral, availability of services, gatekeeping). These were then amalgamated into themes. All authors were involved in discussing and finalising the analysis. Results The analysis focused on the identified barriers to the provision of mental health services for older people in the region. Two main themes were identified: ‘Recognising the Problem’ and ‘Service Availability and Access’. The themes are discussed in detail in the following sections. Only broad information about the service type (general health, mental health, aged care, community service) is provided alongside participants’ quotations in order to ensure their anonymity. Recognising the problem One of the main barriers identified by the participants was the ability of older people, their carers and health professionals to recognise the presence of a mental health problem in the first place. Two issues were identified; the first relates to the attitudes of older people while the second relates to the attitudes of health professionals. In terms of older people’s attitudes, a major barrier was described as older people’s reluctance to admit they might have a mental health problem. Participants described older people’s reluctance to access mental
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health services such as counselling or assessment when it is offered. Participants felt that one reason for this reluctance is the perceived stigma of being labelled as having a mental health problem: . . . to be labelled as having a mental health issue is something that people don’t want to wear. (Community Service)
Some participants saw this as an issue of particular relevance to older people due to differences in generational understandings of mental health problems, while others saw stigma as a potential issue across the generations. Perceived stigma was described as especially pertinent in a small rural community where people’s lives are more visible: . . . it’s a small community and small communities talk. I think there’s that uncomfortable ease and that stigma around a mental health issue. (Aged Care)
Stoicism was described as another attitudinal barrier to older people not seeking mental health care. Participants felt that older people, particularly older men, are less likely than younger people to admit they have a problem, viewing this as ‘a sign of weakness’ (Community Service). Furthermore, older people were described as refusing services because they see others as being more in need of the services than themselves: Sometimes, and I hear it so often, people will say, ‘there are people out there who need it more than me’. They don’t see themselves as needing a service and they always think that there’s somebody worse off than them. (Aged Care)
The final attitudinal barrier to older people accessing mental health care was a lack of trust. Participants noted that older people might feel that if they admit they have a problem, or that an existing problem has exacerbated, they may be institutionalised or subjected to frightening procedures. This may be because of stigmatised notions of how mental health problems are treated: [Older people] have that vision of ECT [Electroconvulsive Therapy] and other mental treatments from their youth . . . so I think that has a lot to do with it. (Aged Care)
This issue may be even greater for older people with previously diagnosed mental health problems whose past relationships with health professionals may lead to a lack of trust in the mental health professions. Participants also identified the attitudes of health professionals as having a role to play. They expressed general agreement that there is a tendency for health professionals to focus on physical illness in consultations with older people while ignoring or dismissing indications of, or a patient’s concerns about, mental health problems: So she went off to the doctor and saw not her own GP but somebody in the system [about a mental health problem].
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. . . so she rang me and she was quite distressed because he had basically said “well what do you want me to do, I can take your blood pressure, I can take your temperature”, so really dismissive. (Community Service)
This lack of understanding of the mental health needs of older people was also identified in relation to the needs of carers, where the focus is on the health of the person being cared for with little awareness of how the carer may be coping with his or her role. Participants also felt that mental health problems in older people in general are not well understood by health professionals, particularly problems that develop in later life as opposed to ongoing mental health problems diagnosed earlier in life. One issue is a tendency to view all mental health problems in older people as dementia related. Another issue is where symptoms of depression or other less severe mental health problems are interpreted as being a normal part of ageing: . . . so many of these needs that people have are wiped off as just being old age, you know, “it’s understandable that you’ll be having trouble sleeping because that just happens when you get old”. (Community Service)
This lack of awareness or understanding on the part of health professionals means that older people are not being referred to appropriate services.
Service availability and access In addition to the attitudes of older people and health professionals towards mental health problems, participants also identified service availability and access as a barrier to effective service provision. In other words, once older people and their health providers understand and accept the need for mental health services, there is still the issue of whether or not these services are available, appropriate and accessible. There were two perspectives on this: participants who stated that the services were simply not available and those who stated that the services were available but not accessed. Participants discussed the inadequacy of services to meet the mental health care needs of older people, particularly in terms of difficulties getting an appointment with local general practitioners (GPs) and mental health services. Specialist psychiatric services and acute mental health services for older people were also described as difficult to access, because they are not available locally and clients either have to travel to a metropolitan service or wait for health professionals to visit. While many participants identified a lack of services, others stated that services are available, but many of these are already at capacity; consequently any increased recognition of mental health problems in older people would most likely mean that services would not be available when needed: . . . the services are available, the services are there but they are already stretched, they’re already at capacity. (Mental Health)
As a result older people who are able to get a referral would have to go on a waiting list, providing a further barrier to effective service provision. There was also a perception among participants that services are generally set up to address physical illness, and that people with mental health problems miss out on available support and services. This is particularly the case with community support: I guess things are set up for physical . . . you’ve got a lot of physical things set up, rails and access, but in the mental health side of things you need a lot more support and I don’t think we do that well in terms of community support for mental health. (Mental Health)
Participants across all services expressed concern that the separation of physical and mental health in service provision was detrimental to older people and that a more integrated and holistic approach would better serve the needs of this population. This issue is further exacerbated by a perceived tendency of mental health services being clinically oriented, neglecting the broader needs of clients (e.g. for social support or in-home support): I think the region in general has limited services. It’s very much the services that are here are very, at the clinical end of services . . . I think in all of the way health services are structured the emphasis is so much on the clinical stuff. (Community Service)
In addition to a lack of availability of adequate services, barriers in accessing services were also identified. This included a lack of knowledge about what services are available and where to access them, both on the part of older people and their families as well as health professionals and services providers: I would assume there is probably a large group of people out there who aren’t accessing services; again because they just don’t know about them, they just don’t know where to start, where to look. They wouldn’t know. (Aged Care)
Barriers associated with transport were also discussed; particularly the difficulty for frail older people in having to travel long distances to access services when they have no personal transport and when there is no public transport. Another access barrier was the lack of effective collaboration between health care organisations, in particular the lack of formal processes for this. A range of organisations were identified as being involved in the provision of care to older people in the region, including residential and community aged care, general health and specialist mental health services, local government organisations and carer support services. Older people may also interact with services outside of this region such as specialist geriatric psychiatric services, acute inpatient mental health care and services specific to particular diagnoses such as dementia or drug and alcohol services. The participants described regular team meetings between local aged care and community services focused around the physical and
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social needs of older people, with mental health services being on the periphery of these relationships. Some participants identified the difficulties with establishing effective collaborative relationships between organisations as resulting from the separation of physical and mental health care, discussed earlier. Mental health services, both within and outside of the region, were generally accessed through referrals and phone calls for advice. Referral was the most commonly identified form of collaboration, but this was described as inefficient as it has to be done through the GP with other services unable to ‘facilitate that directly’ (Mental Health): I think just the process is hard, the system, because you have to navigate a system . . . you have to go via the GP and then they have to refer, and often there’s time that’s going to take with paperwork, this service or that service and get this referral or that referral. . . . It’s a system that people find hard to navigate. (Mental Health)
Having to go through GPs to access services, rather than refer clients directly, was particularly frustrating when GPs did not respond to recommendations from other service providers for referral: I mean the GP service here is the hub of care and I have sent a letter to her GP just explaining, outlining that I have a few concerns, which I’ve had no response on. (Aged Care)
Difficulties were also described with the use of referral pathways due to frequent changes of staff with subsequent loss of knowledge and understanding about these processes: There are formal [referral] pathways but it’s in the working of it, we struggle to maintain it because the minute there is a change in staff on the ground level then that knowledge doesn’t necessarily get passed on. (Mental Health)
Effective referral was often reliant on personal relationships rather than formal pathways to expedite the process. Competition for resources was identified as a barrier to collaboration because instead of working together to provide the most effective and appropriate services for older people, organisations find themselves working against each other as they try to gain their piece of the ‘funded pie’ (Mental Health): Everyone’s trying to compete for a small amount or pool of resources. (Mental Health)
Participants discussed how physical ailments, such as falls or diabetes, often have clear, tangible outcomes, such as reduced falls or better diabetes management after a short assessment and intervention; mental health assessment, however, takes longer and outcomes are not always clear. With funding often allocated on the basis of outcomes, people with mental health problems frequently miss out:
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For example, the falls, that’s got a lot of research base, that’s got set exercises that work, you’ve got set things that you can do, you’ve then got set things that you can give to the GP, you can say “we do falls prevention” and then the doctor says “fall, we’ll refer to there”. . . . mental health is really hard . . . we can’t prove our outcomes. (Mental Health)
Further exacerbating the barriers to effective collaboration is gatekeeping, which occurs where service providers refuse to accept certain people due to the compartmentalisation of services around specific diagnostic criteria. This means that people with complex, interconnecting physical and mental health problems end up being shunted between services as they try to determine who is best to help with different aspects of the problems. This was also described as being difficult when people have mental health problems and dementia: . . . people that do have a diagnosis of dementia are not readily up-taken by mental health services. If you’ve got dementia then you’re over there, if you’ve got dementia and depression well it’s a little harder to get that taken up. (General Health)
Gatekeeping also occurs where community aged care services and residential aged care providers may refuse to accept a person who has a history of aggression, or a service provider refuses a client who has a mental health problem and is likely to bring in less funding than another client with access to a wider range of funding for physical health supports and services. Participants identified that the consequences of delays in access to mental health services and inadequate services provision could be severe. This includes the need for crisis management, hospitalisation and early admission to residential care for conditions that could have been more easily managed had they been identified and addressed earlier.
Discussion The purpose of this study was to explore the barriers to effective mental health care for older people in a rural region in Australia. Overall, the participants viewed care provision to older people with mental health problems as inadequate and ineffective. They identified attitudinal and service-based barriers – what Pepin, Segal, and Coolidge (2009) call intrinsic barriers and extrinsic barriers. Participants’ discussions of intrinsic barriers, both those of older people and health professionals, reflect similar findings on stigmatisation, stoicism and denial as reasons for older people failing to seek and access support for mental health problems (Pepin et al., 2009; Pettigrew et al., 2010; Prins et al., 2008; Wetherell et al., 2004). Similarly the variation in participants’ views of whether stigma is an issue that disproportionately affects older people, or exists across generations, is reflected in other studies (Griffiths et al., 2008; Klap et al., 2003; Pettigrew et al., 2010). Connected to the issue of stigma is that of trust, where older people were identified as having stigmatised ideas of what treatment for a mental health problem
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means (e.g. electroconvulsive therapy [ECT] or institutionalisation). Further, trust was identified as a potential barrier for older people with previously diagnosed mental health problems whose experiences may lead them to be suspicious of the intentions of health professionals. The participants also discussed health professionals’ assumptions about older people and mental health, and the possible impact of ageist notions on the likelihood that older people will be referred to services. According to the National Ageing Research Institute (2009), ageist behaviour is common in medical settings, including a tendency to patronise and listen less to the views of older patients, order fewer diagnostic tests and attribute symptoms to age, rather than treatable conditions. A review by the UK Centre for Policy on Ageing (2009) found that GPs often see depression as ‘just a part of ageing’ (p. 70). Mitford, Reay, McCabe, Paxton, and Turkington (2010) found that older people with first-episode psychosis are often denied access to services, guidelines and funding that are readily made available to younger people. Researchers and commentators have referred to this as the ‘double stigmatisation of older people with mental health disorders’ (Mitford, et al., 2010, p. 1117) due to both ageism and stigma towards mental illness, which limits access to mental health services for older people (Centre for Policy on Ageing, 2009). Participants in our study also discussed extrinsic barriers to mental health care for older people in the region. These barriers are similar to those reported by health services in an Australian survey of mental health service delivery to older people in New South Wales (Draper et al., 2003). In this research Draper et al. (2003) explored relationships between aged care services, adult mental health services and mental health services for older people and found that services were affected by lack of access to specialist staff, resource limitations and inadequate support and liaison between service types. Other studies of gaps in mental health care for older people have identified similar barriers (Centre for Policy on Ageing, 2009; Crotty, Henderson, Martinez, & Fuller, 2013; Knight & Sayegh, 2011). A major barrier identified by participants that has not been previously reported was the perception that the focus of services is on physical health and clinical aspects of mental health care. Participants reported that physical and mental health were addressed as separate issues for the client, with little understanding of the holistic and interconnected nature of the older person’s physical and mental health. This interconnection has been explored in the literature in relation to the general population (Sturgeon, 2007). For example, the World Federation for Mental Health (2004) notes the co-occurrence of physical illness with mental health problems, as well as the frequency with which people with severe and persistent mental illnesses experience a variety of physical disorders and complications. The need for holistic care is likely to be even greater for older people with complex health problems and multiple physical and mental health care needs.
Linked with this is the concern that governmentfunded community support packages are geared towards addressing the needs of clients with physical health problems, and are inadequate to address the needs of older people with mental health problems. For example, Kellett, Shugrue, Grunman, and Robinson (2010) found higher levels of unmet need for agency-based homemaker services and transportation in older people with mental health problems in the USA compared to people with other disabilities. This is of particular concern given that older people with mental health problems experience increased social isolation (Kellett et al., 2010), yet social support and engagement is vital in facilitating access to health services for older people (McCracken et al., 2006). It appears from our study that a wide range of organisations are involved in the provision of care to older people with mental health problems in the region. This array of services is similar to the situation in the United States as discussed by Knight and Sayegh (2011). They identified a multi-system, multi-level and diagnosis specific network of systems of health care available for older people, and into which older people with mental health problems may present due to the complexity of physical and mental health problems and co-morbidity. Participants in our study reported some form of loose collaborative relationship between services; however, they also reported a lack of involvement of mental health services, little knowledge about available services, inadequate referral processes, competition for funding, gatekeeping and a lack of formal collaborative relationships – what Knight and Sayegh call ‘loosely coupled and competing systems of care’ (2011, p. 236). Similar barriers were reported in Crotty et al.’s (2013) survey of external agency views of barriers to collaboration in mental health services for older people. The consequences of this system of service provision was reported to be older people with mental health care needs falling through the gaps between available services, a ‘common conceptualisation of the shortcomings of the mental health care system for older adults’ (Knight & Sayegh, 2011, p. 236). It is clear from the research literature that older people with mental health problems face many of the barriers also identified by our study participants irrespective of where they live; however, there were specific issues associated with living in a rural area that impact on access to mental health services, such as the lack of locally available specialist psychogeriatric and acute inpatient mental health services. The inequitable distribution of publicly funded aged psychiatry services in Australia has been reported elsewhere, with these services generally located in capital cities with limited coverage in regional and rural areas (O’Connor & Melding, 2006). This means that the difficulties that many older people may face with accessing mental health services is further exacerbated by the long distances when they have to travel to metropolitan locations, and when there is a lack of travel resources to do so (Bocker et al., 2012). In addition, long waiting times, lack of after-hours services and poor referral protocols can also be exacerbated in rural areas. For example, Pierce and Brewer (2012) found that prolonged waiting
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times and GP gatekeeping were barriers to the effectiveness of an Australian government funded counselling programme for people in rural areas.
Conclusions This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. More specifically, the study identifies the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people. The study also offers new information and understanding of barriers to mental health care for older people, in particular the impact of the separation of physical and mental health care and the inadequacy of Australian government funded community support packages to meet the needs of older people with mental health problems. The study also provides new insight into the impact of living in a rural region on unmet mental health care needs for older people. Limitations This is a qualitative, exploratory study and as such is limited in terms of generalisability. Additional research needs to be done exploring the extent to which these findings are applicable more generally in rural areas, and in particular in other countries given the differences in health systems. Research exploring older people’s perspectives of barriers to mental health care in rural areas is also needed. References Al-Shammari, S.A., & Al-Subaie, A. (1999). Prevalence and correlates of depression among Saudi elderly. International Journal of Geriatric Psychiatry, 14, 739–747. Australian Bureau of Statistics. (2013). Reflecting a nation: Stories from the 2011 census. Canberra: Author. Australian Department of Health and Family Services. (1997). Care needs of people with dementia and challenging behaviour living in residential facilities. Canberra: Commonwealth of Australia. Bocker, E., Glasser, M., Nielson, K., & Weidenbacher-Hoper, V. (2012). Rural older adults’ mental health: Status and challenges in care delivery. Rural and Remote Health, 12, 2199. Centre for Policy on Ageing. (2009). Ageism and age discrimination in mental health care in the United Kingdom. London: Author. Crabb, R., & Hunsley, J. (2006). Utilization of mental health care services among older adults with depression. Journal of Clinical Psychology, 62(3), 299–312. Crotty, M.M., Henderson, J., Martinez, L., & Fuller, J.D. (2013). Barriers to collaboration in mental health services for older people: External agency views. Australian Journal of Primary Health. Advance online publication. doi:10.1071/ PY12144 Cuddy, A.J.C., & Fiske, S.T. (2002). Doddering but dear: Process, content and function of stereotyping of older persons. In T.D. Nelson (Ed.), Ageism (pp. 3–26). Cambridge: MIT Press. Draper, B., Jochelson, T., Kitching, D., Snowdon, J., Brodaty, H., & Russell, B. (2003). Mental health service delivery to older people in New South Wales: Perceptions of aged care,
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adult mental health and mental health services for older people. Australian and New Zealand Journal of Psychiatry, 37, 735–740. Farrer, L., Leach, L., Griffiths, K.M., Chirstensen, H., & Jorm, A.F. (2008). Age differences in mental health literacy. BMC Public Health, 8, 125. doi:10.1186/1471-2458-8-125 Goldberg, S.E., Whittamore, K.H., Harwood, R.H., Bradshaw, L.E., Gladman, J.R.F., & Jones, R.G. (2012). The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age and Ageing, 41, 80–86. Griffiths, K.M., Christensen, H., & Jorm, A.F. (2008). Predictors of depression stigma. BMC Psychiatry, 8, 25. doi: 10.1186/ 1471-244X-8-25 Gureje, O., Kola, L., & Afolabi, E. (2007). Epidemiology of major depressive disorder in elderly Nigerians in the Ibadan Study of Ageing: A community-based survey. Lancet, 370, 957–964. Judd, F., Jackson, H., Komiti, A., Murray, G., Fraser, C., Grieve, A., & Gomez, R. (2006). Help-seeking by rural residents for mental health problems: The importance of agrarian values. Australian and New Zealand Journal of Psychiatry, 40, 769–776. Kellett, K., Shugrue, N., Grunman, C., & Robinson, J. (2010). Mental illness and long term care needs: Identifying the long term care needs of older and middle aged adults with mental illness. International Review of Modern Sociology, 36(2), 143–168. Klap, R., Unroe, K.T., & Unutzer, J. (2003). Caring for mental illness in the United States: A focus on older adults. American Journal of Geriatric Psychology, 11(5), 517–524. Knight, B.G., & Sayegh, P. (2011). Mental health and aging in the 21st century. Journal of Aging and Social Policy, 23(3), 228–243. McCracken, C., Dalgard, O.S., Ayuso-Mateos, J.L., Casey, P., Wilkinson, G., Lehtinen, V., & Dowrick, C. (2006). Health service use by adults with depression: Community survey in five European Countries, evidence from the ODIN study. British Journal of Psychiatry, 189, 161–167. Mitford, E., Reay, R., McCabe, K., Paxton, R., & Turkington, D. (2010). Ageism in first episode psychosis. International Journal of Geriatric Psychiatry, 25, 1112–1118. National Ageing Research Institute. (2009). Depression in older age: A scoping study. Melbourne: Author. O’Connor, D., & Melding, P. (2006). A survey of publicly funded aged psychiatry services in Australia and New Zealand. Australian and New Zealand Journal of Psychiatry, 40, 368–373. Parr, H., & Philo, C. (2003). Rural mental health and social geographies of caring. Social and Cultural Geography, 4(4), 471–488. Pepin, R., Segal, D.L., & Coolidge, F.L. (2009). Intrinsic and extrinsic barriers to mental health care among communitydwelling younger and older adults. Aging & Mental Health, 13(5), 769–777. Pettigrew, D., Donovan, R., Pescud, M., Boldy, D., & Newton, R. (2010). Mature adults’ attitudes to mental health service utilisation. Australian Psychologist, 45(2), 141–150. Pierce, D., & Brewer, C. (2012). Factors promoting use of mental health services in a rural area of Australia. Community Medicine and Health Education, 2, 11–17. Prins, M.A., Verhaak, P.F.M., Bensing, J.M., & van der Meer, K. (2008). Health beliefs and perceived need for mental health care of anxiety and depression: The patients’ perspective explored. Clinical Psychology Review, 18, 1038–1058. Royal Australian and New Zealand College of Psychiatrists. (2010). Caring for older Australians: Submission to the Productivity Commission public inquiry into Australia’s aged care system. Melbourne: Author.
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Sirey, J.A., Bruce, M.L., Carpenter, M., Booker, D., Carrington Reid, M., Newell, K.-A., & Alexopoulos, G.S. (2008). Depressive symptoms and suicidal ideation among older adults receiving home delivered meals. International Journal of Geriatric Psychiatry, 23, 1306–1311. Strivastava, A., & Thomson, S.B. (2009). Framework analysis: A qualitative methodology for applied policy research. Journal of Administration Governance, 4(2), 72–79. Sturgeon, S. (2007). Promoting mental health as an essential aspect of health promotion. Health Promotion International, 21(S1), 36–41. Thompson, A., Issakidis, C., & Hunt, C. (2008). Delay to seek treatment for anxiety and mood disorders in an Australian clinical sample. Behaviour Change, 25(2), 71–84. Troller, J.N., Anderson, T.M., Sachdev, P.S., Brodaty, H., & Andrews, G. (2007). Prevalence of mental disorders in the
elderly: The Australian National Mental Health and WellBeing Survey. American Journal of Geriatric Psychiatry, 15(6), 455–466. Warburton, J., Cowan, C., & Bathgate, T. (2013). Building social capital among rural, older Australians through information and communication technologies: A review article. Australasian Journal on Ageing, 32(1), 8–14. Wetherell, J.L., Kaplan, R.M., Kallenberg, G., Dresselhaus, T.R., Sieber, W.J., & Lang, A.J. (2004). Mental health treatment preferences of older and younger primary care patients. The International Journal of Psychiatry in Medicine, 34(3), 219–233. World Federation for Mental Health. (2004). World Mental Health Day. The relationship between physical and mental health: Co-occurring disorders. Alexandria: Author.
