Innovations Bring Depressed Elders Back from "Living Hell"

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Culturally sensitive mental health programs for the elderly remain scarce in the U.S.

It's a bright morning in a sunny upstairs room at the Over 60 Clinic in Berkeley, Calif., where seven African American seniors are seated around a conference table for their monthly mental health group therapy.

"I don't want everybody to know I'm going here," declares "Lavern," who, like the others, asks not to be named for this article.

Lavern, in her 70s, leans her cane against her chair. Under her fuzzy brown knit cap, she glares with determination through maroon-framed glasses. She and the others have benefited from individual treatment for depression earlier in the day before joining the monthly mental-wellness maintenance group, which is always followed by a free lunch.

"There's a stigma. In this society we are really prejudiced about mental problems," says Jesse Merjil, a therapist who guides the morning's discussion.

Early Treatment Critical

The Over 60 Clinic is among a growing number of providers that have learned seniors are often more receptive to mental health interventions when they occur in a non-intimidating physical health setting. Mounting research has also shown that early intervention is critical for treating depression and other mental afflictions, before people sink into irreversible distress or even commit suicide.

Mental illness can be set off or intensified by social isolation due to a range of factors, such as loss of family and friends, low English-language proficiency, cultural fears about mental problems or, especially, stressors related to being low income.

Like many other seniors, what "Henry" at the Over 60 Clinic finds "really depressing" is the loss of so many friends. "Men, especially from my generation, have a lot of trouble with grief," he says. "I had a friend pass. He was real close, a buddy. And I'm still a basket case. I couldn't stop crying. I didn't cry when my Mom passed. I was expecting it because she was very old. But she'd had a good life."

Although culturally sensitive programs like the one at Over 60 are growing around the United States, they remain few and far between. According to a 2010 report by the New York Academy of Medicine, for example, "mental health care is particularly underutilized by NYC's ethnic minority communities, especially the black population."

The report cites a 2008 study by New York's Citywide Mental Health Coalition for the Black Elderly, which found that less than one percent of African Americans 65 or older use public mental health services, despite the fact that they are more likely to live alone, be in poverty, contend with discrimination and have greater familial responsibility than their white counterparts.

According to the N.Y. Academy of Medicine report, certain ethnic and racial groups may also "experience barriers to accessing mental health services based on stigma, cultural preferences and religious belief."

Ethnic Elders Suffer Mental Illness at Higher Rates

A whopping 44 percent of New York City seniors are foreign born and speak a total of 170 languages, the report notes. And the city's Asian American seniors in particular "are more likely to suffer from mental illness than the general population."

Prime reasons for the higher rate of mental illness and depression, experts believe, are language isolation and a gulf between the cultural respect afforded to elders in their native lands, and the disrespect they feel from their Americanized children and grandchildren in the United States.

The report found Hispanic elders to have the highest rate of diagnosed depression, one in five. And across all ethnic groups, "women are 50 percent more likely to have been diagnosed with depression."

White and Asian/Pacific Islander males in New York State, however, "committed suicide at more than double the rate of the general population."

"The service system needs to break out of the traditional mental-health framework," said Duy Nguyen, a sociologist at New York University, who is researching housing isolation and related factors that may contribute to mental distress among Asian elders.

"The rate of completed suicides even from the mid-1980s was strikingly high for Asian American elders; men, but also women," he explained. "So we wanted to look more closely at the risk factors."

A preliminary study he and a colleague presented at the recent Gerontological Society of America conference showed that very elderly Chinese seniors in the U.S. "tend to be living at the cultural margins" due to their low incomes, poor command of English and physical limitations.

"It's important to go where ethnic seniors congregate, such as senior centers, or go to their homes through (programs) like Meals on Wheels, and to integrate mental health as part of other services people are comfortable with," stressed Nguyen.

Homebound Seniors in Texas

Homebound seniors have the greatest unmet psychosocial needs, according to Namkee Choi, a social researcher at the University of Texas, Austin.

"They are the most socially isolated, and they tend to be low-income," Choi said. "Once they become so sick or frail that they can't leave their homes, they use up any savings or resources they might have had."

Her research team has found that up to 40 percent of low-income elders experienced depressive symptoms. The principal cause of late-onset depression, Choi said, is an unforeseen health condition. "The second primary reason is the death of a loved one or loss of a family member, such as having a grandson in prison," she said.

"As social workers, our job is to reinforce their coping skills to deal with life problems," says Choi. "We tell them, 'You have coping skills already—that's why you've lasted this long.'"

Wave of the Future

But new approaches that utilize technology to detect and treat mental illness in its early stages can also help seniors cope, says Choi.

"Teletherapy is the future wave," she says.

The two-year project lends laptop computers to homebound seniors, who are first screened by MOW case managers. Using Skype software to facilitate two-way video conferencing, elders receive six weekly therapy sessions, plus once-a-week follow-up calls for six months. A therapist phones the seniors from the university to let them know when they should sign on to Skype. "We take the therapist into their homes," Choi said.

The program - one of several around the nation testing innovative approaches funded by the National Institute of Mental Health (NIHM) in home and community settings - has about 180 participating elders of whom about half are white, a quarter are Latino, and a quarter are African American.

Choi was surprised to find that none of the participants resisted therapy because of a mental health stigma. She speculated that these homebound elders were desperate for any help because "they are caught in a living hell."

Initial results of the "teletherapy" have been promising, said Choi. Almost no difference has been detected between the effectiveness of teletherapy and more costly in-person visits.

Finding new ways to reach mentally vulnerable seniors before they become gravely impaired is imperative, said Choi, especially in this period of scarce government resources. "These seniors are in a precarious situation," she observed. "It only takes one chronic condition like a cancer diagnosis or a stroke and they are at the end of their rope."

Choi recounted a recent "success story" with a woman, age 63, who'd had a stroke, followed by surgery for a torn retina. "She became very depressed. But we were able to work with her to the point where she can function again and is ready to go back to work."