Ethnic Seniors Grapple with Depression--Alone

Managing her diabetes day-to-day is a constant struggle for Maria Carr. Like so many black elders, the 68-year-old San Franciscan must wrestle so much with the debilitating effects of chronic illness—the neuropathy that weakens her ability to walk or the continual pin pricks to test for blood sugar levels—that it gets her down.

It's in those low hours that Carr's thoughts often drift back to her "rotten childhood" on a farm in her native Jamaica and the constant verbal abuse she endured from her stepfather.

"People think about their past history," said Carr. "I'm prepared for the worst. I'm not in the best health, but my mind is still okay. When I get depressed, though, it's very difficult. Sometimes I wish I could die."

Carr is among the four in 10 black older women who live alone in the United States. She is philosophical about her condition and knows that chronic illness can set off bouts with depression.

According to the Centers for Disease Control and Prevention (CDC), depression is the most prevalent mental health problem among older adults.

Although groups of ethnic elders experience percentages of serious depression similar to that of older whites (about one in six people ages 50 or older at some point) mental health experts say that African-American, Latino, Asian and Native-American seniors are less apt to get treated. That's because of their higher levels of poverty, lack of insurance or access to treatment and the pervasive stigma of mental illness in many cultures.

Left untreated, depression, anxiety disorder and related conditions can result in debilitating physical ailments, as people eat and sleep more poorly and become less physically active.

And untreated depression can lead to suicide. Older adults have the highest suicide rate in the United States. Although seniors make up 12 percent of the population, they accounted for 17 percent of suicides in 2005, according to the Suicide Prevention Action Network,

For those who might resist getting mental health assistance, Maria Carr advised her fellow ethnic seniors, "Depression can lead to terrible consequences. You cannot overcome depression on your own. If people are feeling depressed, they should start by asking their doctors about it."

Patricia Arean, a professor of psychiatry at the University of California, San Francisco, emphasized, "One of the big issues for ethnic elders is the stigma attached to mental illness."

Arean explained that ethnic seniors might sink into depression because of the loss of a spouse or in response to chronic illness. Many delay seeking professional help because they fear being considered "crazy," she said, and "by the time many get to mental health services they are very ill, often enough to be hospitalized."

The health care system also erects barriers to mental health care, she said. For instance, Medicare's toll-free 1-800 number is very difficult to navigate for people with low English proficiency. In addition, compounding the lack of accessible services is a low reimbursement rate for mental health services by Medicare and other insurers, which discourages even providers interested in working with elders from entering geriatrics.

Arean, who is Cuban American, noted that among immigrants, the hurdles to seeking help can go beyond language difficulties in trying to relate their mental distress. Those from politically oppressed countries, she said, may avoid any mention of their state of mind. "In dictatorships, mental health problems can be a reason for imprisonment," she observed.

Even when mental health services are available, she went on, the setup at local mental health services are commonly unfriendly to people open to using them. A 20-minute appointment can turn into a three-hour ordeal for a working son or daughter needed to pick up and deliver an elderly parent, return home and go back to work.

In recent years, Arean said, geriatric mental health experts have developed new approaches to screening for treatable depression among elders in health care clinics and doctors' offices.

The Impact program, developed at the University of Washington, Seattle, for example, has physicians around the United States working with consulting psychologists and care managers, who can help depressed patients so effectively that their symptoms diminish by half or better within a year. What's more, Impact programs were found to reduce total health care costs for each older patient by $3,300 over four years, a potential savings of billions of dollars for Medicare and Medicaid.

"The professional literature on mental-health challenges for ethnic seniors shows lots of research, but few interventions targeted to them around the country," said Margarita Alegria, director of the Center for Multicultural Mental Health Research at Harvard Medical School

"We get a lot of requests to help elders, especially older Latinos, but also Haitian and Asian seniors. Many find themselves marginalized and isolated, and that places them at risk," she said.

Many ethnic seniors face a range of social factors blocking them from seeking needed care, Alegria stressed, such as living in high-crime neighborhoods and lack of safe, affordable housing.

"These are people behind closed doors, so they have no easy access to social safety nets," Alegria observed. "In their old countries, the elders could sit with their neighbors in a park or in a café and talk to people. But that's not possible where there is a high level of violence and gangs." Also, she said, older immigrants may be undocumented and fear being exposed, if they seek help.

In San Francisco, Carr knows she's lucky. Unlike most of the growing ranks of ethnic elders and older immigrants in the United States, she has access to programs each day that not only tend to her physical health, but also monitor her mental well being.

Carr, who is covered both by Medicare and Medi-Cal (California's Medicaid program for low-income people), attends the local Institute on Aging's adult day care center several times a week. The program offers social activities for frail seniors and comprehensive health care, including a psychiatrist on staff, who referred her for daily calls from the Institute's Friendship Line, a suicide prevention and counseling service.

The Friendship Line staff call Carr every afternoon to make sure she's all right and remind her to take her prescriptions. "If I'm out, they'll even call me as late as 10 o'clock at night to check on me," she said.

Daniel E. Jimenez, a research associate at Dartmouth Medical School, said that while mental health professionals should be more aware of multicultural perceptions about mental illness, they also need to remain flexible and creative in their work with elders, who don't take easily to some established practices of psychotherapy.

He recalled an older Latina he worked with in California. As a participant in a therapy group for people providing care to frail older family members, she was the only one to resist using techniques Jimenez was teaching to reduce the enormous stress that can come with family caregiving.

Jimenez recalled, "When I asked her why she wouldn't engage in the stress reduction, she told me, 'Because I'd let the devil in.'" Even though the scientific strictures of psychotherapy prohibit any involvement with religion, Jimenez decided to ask the woman to discuss the stress-reduction with her pastor, who agreed that the meditation could help her.

Going further, Jimenez persuaded the woman to close her eyes during the stress-reduction meditation and imagine Jesus waiting for her in the room. Eventually, he agreed that she'd be fine substituting prayer in church for the psychological technique. "She did great," he said, when he followed up with her later.

"Clinicians need to understand that the person coming in the door often has a vastly different idea of what they are going through," Jimenez stressed. Especially with multicultural patients, he added, "It's the duty of every clinician to follow the lead of the patient. You'd be surprised what a powerful clinical tool listening can be."