Is it too late to prevent a decline in mental health care for older Australians?

Over the next 20 years, the number of Australians aged 65 years and over is projected to nearly double from around 3.2 million to about 6.2 million people.1 Individuals with lifelong mental illness will be joined by those with new mental disorders, such as mood disorders, late-life psychoses and anxiety disorders that are often associated with physical illness or cognitive decline, including dementia.2,3 Australia is failing to plan for these changes and minimise the associated financial and personal costs this will bring. Males aged over 85 years already have the highest suicide rate in Australia.4 The 2009 Fourth national mental health plan discussed the needs of older people, but without priority actions focused on older people.5 Similarly, the Independent Mental Health Reform Group’s (IMHRG) $2.5 billion “blueprint” for the transformation of mental health services in Australia largely ignored older people.6

There is a narrow window of opportunity for essential change. The government response to the Productivity Commission report Caring for older Australians7 and the Ten year roadmap for national mental health reform8 from the Council of Australian Governments will have a major influence upon the standard of mental health care received by older Australians. This article outlines the types of changes required.

The 1992 National mental health strategy aspired to major improvements in the quality and range of mental health services.9 Initial reform focused on replacing stand-alone psychiatric hospitals with specialist services in the community and general hospitals. This has been extremely variable for older people, with an overall failure to provide specialist community mental health care.

In the 2008–09 financial year, people aged 65 years and over had less than half the per capita rate of contacts with community mental health services by state as people aged 25–34 years,10 with over 100% variability between states. Older people’s use of the newly funded psychologist services was less than 25% of that by people aged 25–34 years.10 Examination of all Medicare-funded psychiatrist consultations has repeatedly shown that older people have much less access to psychiatrists than younger adults. Access to psychiatrists is particularly poor in those aged 85 years and over — the most rapidly expanding age group — who receive less than 12% of the per capita Medicare psychiatric services per annum of people aged 25–64 years.3 This is a pattern noted in both public and private settings.3 There are no accurate data to benchmark the appropriate level of contact, but it seems that the low use of specialist mental health by older people is not a reflection of what is seen by Australian general practitioners. Much higher rates of depression are reported in general practice patients aged 60 years and over than were noted in the 2007 National Survey of Mental Health and Wellbeing, where methodological weaknesses in the survey instruments are likely to have resulted in an underestimate of the rates of anxiety and depression in late life.2,11 Nearly a quarter of all mental health-related encounters in general practice are with patients aged 65 years and over, but GPs provide less than half the rate of specific mental health care (using Medicare Benefits Schedule items) to this age group than they do to younger people.10 A recent study has noted the excessive prescription of psychotropic drugs to older Australians, with the rate peaking in women aged 90–94 years, who have the highest population-standardised rates of antipsychotic, antidepressant and anxiolytic sedative hypnotic drug prescription. Classes of psychotropic drugs are being prescribed at a rate 500% higher to this age group compared with the general population, suggesting that even patients with mild disorders are being treated with drugs.12 GPs self-report that they lack confidence in managing common mental disorders in late life, and when combined with workforce shortages (both mental health professionals and GPs), particularly in rural Australia, such problems magnify.

Older people also have very limited access to community residential places provided under the Commonwealth State Territory Disability Agreement for people with onset of disability before age 65.10 Despite noting the concern of the Senate Standing Committee on Community Affairs about “generic” mental health programs not meeting the specific needs of the aged, the Evaluation of the FaHCSIA targeted community care mental health initiatives contains no age demographics.13 The failure to provide adequate community mental health services for older people may be reflected in the rates of mental illness in residential aged care, and the relatively high use of hospital services for mental disorders by older people.10

There appears to be an ongoing hope that aged care services will either fill the gap left by mental health, or achieve integration by hosting mental health services. For example, the IMHRG’s only recommendation for the assessment of older persons with mental health problems was “collaborative geriatric medical teams, equipped for home visits and drawing on psychiatric assistance as necessary”6 (our italics). This ignores the evidence base that has shown such approaches to be ineffective.14 For people with multiple needs, focusing on one area of integration often creates new problems at other interfaces and places unattainable expectations upon the levels of knowledge and skills of staff. It also ignores the opinions of aged care providers who believe that they need the support of mental health services. This is not surprising given the findings of the recent report of the Aged Care Funding Instrument, that 77% of residents had a mental health issue, including 25% of all residents with such a disorder without dementia.15

Australia must commit to valuing the mental health of older people, recognising their right to appropriate care and ensuring such care is provided. The complexity of support needs for older people with mental illness increases just as it does for other older people; this is further complicated by stigma and increased rates of illness. No single service structure can deliver effective mental health interventions and meet these needs.

Current obstacles to older people with a mental illness accessing support and mental health services must be removed. Mental health, aged care and Medicare guidelines must facilitate access to services based on needs rather than age or residence. Priority should be given to removing practices that impede older people’s access to aged care or mental health community residential care supports, and to people in residential care accessing Medicare- or state-funded mental health services. The role of “general” mental health services in providing care to older people with ongoing mental illness, who have “successfully aged” without becoming frail or developing multiple physical health problems, and in after-hours care, should be supported through collaboration with age-specific services.

The needs of older people and their carers must be the focus of care by all services,16 including those providing:

• support and primary health care;

• individual clinician mental health care; or

• multidisciplinary mental health care.

Those providing support or primary health care require sufficient training to develop an understanding of how mental illness may present in older age and to allow interventions appropriate to their role. Elements of “mental health first aid”, information materials, peer support and health promotion initiatives should be routinely adapted to the needs of older people.

Mental health interventions must be evidence-based for older people and delivered by an equitably distributed, suitably trained workforce, despite national and international shortages. If the low rates of provision of care by individual mental health providers are to be remedied, such training must be integrated into the curricula of all potential providers of mental health care, especially GPs and psychologists.

Individual mental health care must be supported by adequate access to specialist multidisciplinary input across the spectrum of disease severity, including prevention. This should be delivered through collaborative partnerships between multidisciplinary aged mental health teams, with nursing, psychiatrist and allied health staff able to intervene in all settings (including aged care facilities), and other key providers. The Framework for service planning and care delivery proposed by the Psychogeriatric Care Expert Reference Group, which was endorsed by the Ministerial Conference on Ageing in December 2010, is consistent with this model.17

Adequately staffed and trained multidisciplinary mental health teams, working in collaboration with key partners, have the best evidence for efficacy in working with older people.14,16 These teams should provide care directly, and work to increase the capacity of partners and to better integrate the input of private mental health providers. Inadequate access to mental health services in any areas must be redressed. This would be best achieved through national benchmarks for the availability and quality of mental health services for older people, supported by specific steps for the attainment of these benchmarks in all mental health plans and workforce strategies. Benchmarks should be based on the epidemiology of the mental health and wellbeing of older Australians, developed using age-appropriate instruments, and should include those in residential aged care facilities and those with dementia.

The current policy focus on youth mental health is understandable, but not when accompanied by the neglect of mental health among older people. Effective mental health care for older people can be delivered, but only with consistent leadership, commitment, resources, workforce development — and time. With a rapidly ageing population, and workforce deficiencies, time is running out. If Australia does not act now, it may well be too late.