More than half (52%) of aged care residents have symptoms of depression, compared with 10-15% of older people living in the community. As well as feelings of sadness and low mood, aged care residents with depression feel uninterested in activities, hopeless about the future, guilty about the past and may desire death.
Some actively contemplate taking their own lives. The prevalence rate of suicidal thoughts in residential aged care settings can be as high as 46%. This is more than three times the rate found in older adults who are housebound but in the community.
People entering residential aged care facilities are, on average, older than those living in the community. They have more complex care needs due to physical and cognitive difficulties. They may also have difficulties adjusting to their loss of independence and routine. These factors all increase their risk of depression and suicidal ideation.
However, mental illness often remains undetected among aged care residents.
There are several reasons for this. People living in residential aged care usually have complex care needs, making the identification of depression difficult, as the emotional symptoms become confused with those of other conditions. Older people are also less likely than younger people to recognise their own symptoms, often attributing them to normal ageing.
Further, although facility-based carers are in a position to act as informants, they often lack the training to detect symptoms of depression and do not routinely screen for suicide ideation.
Depression is a manageable condition and the symptoms can be improved or managed through therapy and medication. Medications are effective but are often associated with side effects, and for older adults may not be recommended alongside some other medications and conditions.
Yet, when residents are recognised to have symptoms of depression, they are often only prescribed medications (particularly antidepressants) despite the effectiveness of non-medication approaches. Research shows interventions such as cognitive behavioural therapy (a talk therapy that addresses how you think and act) are at least equally effective as anti-depressants for improving late-life depression.
Other interventions such as exercise, music and singing, animals and pet therapy, reminiscence-based activities (such as reviewing one’s life, talking with others about the past), behavioural activation (such as doing pleasant activities) can also be effective.
The poor use of therapy and non-drug interventions is the result of a number of factors.
First, funding for such activities in residential aged care is limited. Residents in government-subsidised places are not eligible for Medicare rebates, under programs such as Better Access, to see a psychologist. In contrast, those living in the community have access to such rebates. Psychologists and other mental health care professionals are rarely employed within such residential settings.
Second, psychologists and other mental health care professionals are rarely trained to work with older adults, much less with those with cognitive impairments or who are living in residential settings. We need more training in the field of clinical geropsychology.
Third, residents and professional care staff may regard psychological care as stigmatising and impractical, given the presence of physical and cognitive co-morbidities. Such perceptions are inconsistent with research evidence on the benefits and adaptability of a range of non-medication interventions for older adults living in residential care.
Outreach programs may address gaps in service delivery and education. Swinburne University, for example, has operated a well-being clinic for older adults, a specialised service to provide counselling to older people in residential care. Postgraduate students travel to the facilities to offer these services.
We have learnt from this experience that counselling and other psychological and social activities can be extremely effective approaches to helping our elders feel less alone, less depressed and less hopeless. Rather than simply medicating the growing proportion of Australians who are admitted to aged care, we need to treat the whole person and the underlying causes of their depression.
For support in a crisis, please call Lifeline Australia on 13 11 14 – a 24-hour, confidential service available from landlines, payphones or mobiles. If your life or anyone else’s is in immediate danger, call 000.
Sunil Bhar is the co-founder of The Wellbeing Clinic for Older Adults.