Despite the promise of mental health and aged care reform in recent years, older people with mental illness continue to be overlooked.
Gary* had been living on the top of a noisy rural New South Wales pub for four months before arriving at St Francis Residential Aged Care in Orange.
Without money or social supports he frequently took up offers of temporary accommodation in between admissions to Bloomfield hospital for psychiatric treatment.
Clinical leader Kathryn Groves says many of St Francis’ 14 complex mental health residents have histories of homelessness and extended stays in psychiatric institutions.
“A lot of these residents have quite fractured relationships with their family, so there was no support network for them in the community. They were often malnourished, on the wrong medications, either in debt or had no money and faced stigma related to their mental illness,” she says.
For the past two years, the team at St Francis has been accommodating older people with complex mental illness from Bloomfield mental health hospital to ensure they receive appropriate care and support in the least restrictive environment possible.
“When we decide to take a person from Bloomfield, it’s a multidisciplinary approach,” she says.
Residents are linked into the community mental health team, as well as to occupational therapy, speech pathology, social work and nutrition services. All care staff have also undergone training in mental health first aid.
While facilities like St Francis are the exception rather than the rule in aged care, Groves says she expects mental health care to become an increasingly critical issue for the sector.
A long road ahead
While general awareness of the needs of older people with mental illness is increasing, Dr Rod McKay, conjoint senior lecturer with the school of psychiatry at the University of New South Wales, says many systemic and attitudinal barriers remain.
In fact, older people’s access to mental health services has been falling behind the rest of the population and suicide in Australia is highest among men aged 85 and over.
“In national trends, the increase in access to mental health services that governments have been working on has been much more effective for younger people and people in mid-life than older people,” says Dr McKay. “Older people have had very limited increase in access to services.”
For example, access to GP mental health services by people 65 and over is 35 per cent less than the rate of younger people and access to psychologists is around 21 per cent less.
In residential aged care, older people are excluded altogether from Medicare-funded psychology services, most likely due to perceptions of perceived double funding of services. However, very few providers are able to fund these services through current aged care subsidies.
Barriers to mental health care
Looking at the aged care system, many mental health advocacy groups have identified areas of discrimination against older people with mental illness and have called for special recognition within the Aged Care Act.
In its submission to the Living Longer, Living Better reform process, the Royal Australian and New Zealand College of Psychiatrists says access to aged care services for older people with a mental illness is still conditional on a person having a predominately aged-related disability.
“Not only does this appear to contradict the inclusion of psychological need as a reason for requiring residential care in the Aged Care Act, it would also appear to contribute to RACF providers’ lack of preparation to meet these needs,” says the RANZCP.
The professional peak body says this position excludes older people from care based on the presence of a mental health condition and therefore is discriminatory and ultimately detrimental to the wellbeing of older people.
In its own submission to government, the National Mental Health Commission (NMHC) says discrimination through lack of recognition of older people with a mental illness is contrary to Article 12 of the UN Convention on the Rights of Persons with Disabilities and must be explicitly addressed in the aged care system.
Advocacy for ‘special needs’ status
To improve recognition and support for older people with mental illness, some groups have pushed for formal recognition within the Aged Care Act. Special needs status has been supported by a number of organisations which, along with the NMHC and RANZCP include the Consumers Health Forum of Australia and the former Labor government’s Psychogeriatric Care Expert Reference Group.
There are currently eight groups with special needs status in the aged care system, most recently LGBTI people, people who are homeless or at risk of homelessness and people who were in institutionalised care as a child.
Professor Allan Fels, chair of the NMHC, says given the links between mental health and aged care and the alarmingly high prevalence of mental illness among older people, explicit recognition is essential.
Dr Rod McKay, who also supports the recommendation, says unlike services in the community, the aged care system is currently not accountable under any specific mental health standards.
“Having recognition as a special needs group would start the process of ensuring that good care of mental illness is not dependent solely on good leadership within organisations or residential facilities,” he says.
“It would also help to create a focus at looking at what are the systemic barriers to providing that good care and also opportunities to highlight quality care.”
Any wins in LLLB?
As part of the Living Longer, Living Better reform package legislated in June 2013, the Australian Greens tried to negotiate for the inclusion of a separate mental health supplement to support the delivery of care to this group.
While the Greens’ advocacy for a homeless supplement won support, the government rejected a specific mental health supplement and instead agreed to expand the dementia supplement to recognise cognitive impairment and severe and complex behaviours.
The former minister for mental health and ageing Mark Butler also agreed to review older people’s access to mental health services in the 2016-2017 review of the reforms.
Senator Rachel Siewert, Australian Greens spokesperson on ageing, tells AAA that while the expanded dementia supplement was welcome, it would not address the broader mental health needs of older people.
“It is really clear that there are mental health issues beyond dementia and I remain concerned that broader mental health needs may be missed out,” she says.
Significantly, the new dementia and severe behaviours supplement, which came into effect from August 2013, will not target the large numbers of people in residential aged care with symptoms of depression due to its focus on challenging behaviours.
According to a recent report by the Australian Institute of Health and Welfare more than 50 per cent of permanent aged care residents show signs of depression. This finding was much higher than previous estimates and five times higher than current estimates of depression in older people in the community.
Siewert says she is seeking the same commitment from the new minister responsible for mental health, Peter Dutton, to review the need for a specific mental health supplement for older people in 2016.
A comprehensive approach
While targeted supplements are an important funding mechanism, mental health experts acknowledge they form only part of the picture for effective reform.
Other important drivers include improved training for GPs and aged care staff, embedding standards for mental health care in aged care accreditation and increasing collaboration and coordinated service planning between the mental health and aged care sectors.
McKay says defining the core responsibilities of mental health and aged care services in the treatment of mental health illness in older people is a fundamental first step.
He says for too long responsibility for mental health treatment in aged care has been unclear, which has hampered appropriate planning and policy direction at a national level.
While there was considerable optimism around the appointment in 2010 of Australia’s first federal minister for mental health and ageing, McKay says there were more missed opportunities than real gains during Butler’s term.
“I don’t think there was a sense of connection and need to connect the two portfolios of ageing and mental illness.
“Unfortunately those portfolios have been even further separated in the new government, which really is cause for significant concern.”
McKay says it has been a very difficult task to maintain policy momentum around the mental health needs of older people. Tellingly, in 2008, then minister for ageing Justine Elliot commissioned a report into residential care and people with psychogeriatric disorders and subsequently set up a 14-member Psychogeriatric Care Expert Reference Group to devise a framework for psychogeriatric services. That framework was never publicly released or developed into government policy.
Tackling stigma and ageism
Jack Heath, CEO of SANE Australia, says older people with mental illness face the double stigma of ageing and mental illness, which can also act as a barrier to the treatment and support for older people when they show symptoms.
He says there is a dangerous misconception that depression is a natural part of ageing and calls for improved awareness and training targeting the aged care sector.
“There have been many changes to aged care policy, but there is still a lack of attention to mental illness in the elderly. If we are to work towards an inclusive society then we must consider all its citizens,” he says.
McKay agrees that stigma surrounding ageing and mental illness has a significant impact. Interestingly, cross-cultural research from Europe is showing a link between social attitudes towards older people and lower suicide rates in this age group.
“We have a lot of work to do in reframing what we think age is about,” says McKay. “It is about ongoing contribution rather than the sense of being a burden with an inevitable decline and inability to contribute.
“I think within that context we will have more hope that mental illness in later life will be seen as something that isn’t normal and can be treated.”
*Not his real name.
This article first appeared on Australian Ageing Agenda on 28 January, 2014.