Age, ethnicity, and mental illness: a triple whammy

Mental health of the ageing immigrant population

About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population.

Environmental Press, Aging in Place, and Residential Satisfaction of Urban Older Adults

Sociologists who study and work with older adults often use the term “aging in place” when discussing older adults' residential environments. Aging in place suggests that what is best for older people (and society at large) is to remain in the residential environment (e.g. home and neighborhood) in which they have lived most of their lives. The goal of this study was to utilize the theory of environmental press in a sample of older adults living in the central city of Detroit to begin to understand their levels of satisfaction with their residential environment, and to examine potential limitations in the theory of aging in place.

A random telephone survey was used in a sample of older adults (n = 604) living in the central city of Detroit, Michigan. Hierarchical logistic regression was used to test residential satisfaction using demographics, home hazards, neighborhood hazards, personal competencies, geographic location, and interaction variables. Home hazards, neighborhood hazards, geographic location, and interaction press measures predicted housing satisfaction (Nagelkerke R2=40.2 percent) and neighborhood satisfaction (Nagelkerke R2=50.5 percent). The environmental press and residential satisfaction of the highest and lowest mentally and physically functioning older adults were also investigated. Respondents who reported the lowest levels of mental and physical functioning also reported the lowest levels of residential satisfaction and faced the greatest environmental challenges. The results suggest that older adults occupying disadvantaged social locations may be overlooked in current practice definitions of aging in place.

Adapting Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs to Culturally Diverse Clinical Populations

OBJECTIVES

To review the literature on the screening, brief intervention, and referral to treatment (SBIRT) approach to alcohol and drug use with racial and ethnic subgroups in the United States and to develop recommendations for culturally competent SBIRT practice.

METHODS

Articles reporting on the use of SBIRT components (screening, brief intervention, referral to treatment) for alcohol and drug use were identified through a comprehensive literature search of PubMed from 1995 to 2015.

RESULTS

A synthesis of the published literature on racial and ethnic considerations regarding SBIRT components (including motivational interviewing techniques) was created using evidence-based findings. Recommendations on culturally competent use of SBIRT with specific ethnic groups are also described.

CONCLUSIONS

On the basis of the literature reviewed, SBIRT offers a useful set of tools to help reduce risky or problematic substance use. Special attention to validated screeners, appropriate use of language/literacy, trust building, and incorporation of patient and community health care preferences may enhance SBIRT acceptability and effectiveness.

PRACTICE IMPLICATIONS

Providers should consider the implications of previous research when adapting SBIRT for diverse populations, and use validated screening and brief intervention methods. The accompanying case illustration provides additional information relevant to clinical practice.

EPA Guidance Mental Health Care of Migrants

Migration is an increasingly commonplace phenomenon for a number of reasons. People migrate from rural to urban areas or across borders for reasons including economic, educational or political. There is increasing recent research evidence from many countries in Europe that indicates that migrants are more prone to certain psychiatric disorders. Because of their experiences of migration and settling down in the new countries, they may also have special needs such as lack of linguistic abilities which must be taken into account using a number of strategies at individual, local and national policy levels. In this guidance document, we briefly present the evidence and propose that specific measures must be taken to improve and manage psychiatric disorders experienced by migrants and their descendants. This improvement requires involvement at the highest level in governments. This is a guidance document and not a systematic review.

Mental health services for black and minority ethnic elders in the United Kingdom: a systematic review of innovative practice with service provision and policy implications

BACKGROUND

The proportion of older people from black and minority ethnic (BME) groups in the United Kingdom (UK) is increasing steadily as the population ages. The numbers with dementia, depression, and other mental health problems are predicted to increase. Government policy documents have highlighted gaps in services for BME elders and/or the need to develop culturally appropriate services, in order to prevent people from BME communities from becoming socially excluded and finding services hard to access. This paper reviews published examples of innovative services and key learning points from them.

METHOD

A search was carried out on Pubmed, Medline, and Google Scholar for service developments aimed at BME elders in the UK. Sixteen relevant papers and reports were identified and were analysed to identify learning points and implications for clinical practice and policy.

RESULTS

Commissioning issues included were forward planning for continuing funding and mainstreaming versus specialist services. Provider management issues included were employing staff from the communities of interest, partnership, and removing language barriers. Provider service issues included were education for service provider staff on the needs of BME elders, making available information in relevant languages, building on carers' and users' experiences, and addressing the needs of both groups.

CONCLUSION

A model for structuring understanding of the underutilisation of services by BME elders is suggested. The main emphasis in future should be to ensure that learning is shared, disseminated, and applied to the benefit of all communities across the whole of the UK and elsewhere. Person-centred care is beneficial to all service users.

Why may older people with depression not present to primary care? Messages from secondary analysis of qualitative data

Depression in older people is common, under-recognised and often undertreated. This study aimed to explore the reasons why older people with depression may not present to primary care. Secondary analysis was carried out, of qualitative data collected in two previous studies in North-West England. Older people are reluctant to recognise and name 'depression' as a set of symptoms that legitimises attending their general practitioner (GP). They do not consider themselves candidates for help for their distress. This is partly due to perceptions of the role of the GP but also to previous negative experiences of help seeking. In addition, treatments offered, which are predominantly biomedical, may not be acceptable to older people. Interventions offered to older people need to encourage social engagement, such as befriending, and enhancement of creative, physical and social activity.

Gay and lesbian carers: ageing in the shadow of dementia

This article reports on findings from a qualitative study, undertaken in England, which explored the experiences of 21 gay men and lesbian women who care, or cared, for a person with dementia. The aim of the study was to explore this experience through the lens of a person's gay or lesbian sexuality. The paper reports two related themes that emerged from the wider study – respondents' hopes, fears and plans for the future and, specifically, the way in which their caring experiences had coloured their views and expectations of how their own health and social care needs may be met. Respondents' narratives reflect a range of pervasive anxieties about the future. First, about the possibility that they might be diagnosed with a condition such as dementia and, consequently, the myriad ways in which their sexualities and lifestyle choices may be perceived and interpreted as they themselves age and, possibly, require health and/or social care and support. In light of these concerns, respondents reflected upon the need for specialist service provision for older gay and lesbian people – an idea that was, perhaps surprisingly, not universally welcomed.

Use of translated versions of the MMSE with South Asian elderly patients in the UK

The elderly population is increasing all over the world, a trend expected to continue well into the next century, particularly in low-income countries (Levkoff et al, 1995). There is an established association between increasing age and cognitive decline (Fillenbaum, 1984) and dementias are common in this age group.

Use of translated versions of the MMSE with South Asian elderly patients in the UK

The elderly population is increasing all over the world, a trend expected to continue well into the next century, particularly in low-income countries (Levkoff et al, 1995). There is an established association between increasing age and cognitive decline (Fillenbaum, 1984) and dementias are common in this age group.

Concepts and understandings of dementia by 'gatekeepers' and minority ethnic 'service users'

In this article I outline research which seeks to explore the intersections of dementia, ethnicity and family care. My focus is how research that aims to focus on dementia care and ethnicity illuminates the experiences of members of minoritized ethnic groups in accessing statutory services. I reflect on how the intersections of racialized identities and western medical terminology make researching and providing services across racialized boundaries and health/illness a complex procedure. This commentary has direct implications for the care of people with dementia, their family members and for service development within health and social care fields.

Education effects on cognitive function in a healthy aged Arab population

BACKGROUND

The Mini-mental State Examination (MMSE) has not been validated in Arabic speaking populations. The Brookdale Cognitive Screening Test (BCST) has been developed for use in low schooling populations. We investigated the influence of gender, education and occupation in a cognitively normal community sample which was assessed using an Arabic translation of the MMSE and the BCST.

METHODS

Cognitively normal subjects (n=266, 59.4% males, mean age (SD): 72.4 (5.5) years) from an Arab community in northern Israel (Wadi Ara) were evaluated. Education was categorized into levels: 1=0-4 years, 2=5-8 years, 3=9-12 years. Effects of gender, education and occupation on MMSE and BCST were analyzed by ANOVA, taking age as a covariate.

RESULTS

The mean MMSE score of males [26.3 (4.1)] was higher than that of females [23.6 (4.2) points]. Two-way ANOVA showed a significant interaction between gender and education on MMSE (p=0.0017) and BCST scores (p=0.0002). The effect of gender on MMSE and BCST was significant in education level 1 (p<0.0001, both tests) and level 2 (p<0.05, both tests). For education level 1, MMSE and BCST scores were higher for males, while both scores were higher for females in education level 2. The effect of occupation was not significant for both genders.

CONCLUSION

Education and gender influence performance when using the Arabic translation of the MMSE and BCST in cognitively normal elderly. Cognitively normal females with 0-4 years of education scored lower than males. These results should be taken into consideration in the daily use of these instruments in Arabic.

'They're all depressed, aren't they?' A qualitative study of social care workers and depression in older adults

Statutory and voluntary social services provide care and support for vast numbers of vulnerable older adults, yet little is known about how social care practitioners respond to depression in this high risk population. This study elicited the perceptions and conceptualizations of this condition among social care staff, and views on how the response of social care and other agencies might be improved. Qualitative interviews were conducted with 20 social care practitioners working in generic services for older adults in south London. Depression was perceived to be remarkably common among clients, a phenomenon largely attributed to the adverse circumstances of old age, particularly social isolation. A key message from participants was that social causes indicate a need for social interventions. While primary care was criticised for not taking depression seriously in older people, mental health services were generally praised. Expansion of social, recreational and psychological interventions was advocated.

The debate on ethnicity and dementia: from category fallacy to person-centred care?

The concept of ethnicity remains attractive and meaningful to service developers and professionals, although research suggests that this disguises other facets of identity and difference. An epidemiological perspective on the relationship between ethnicity and dementia supports the idea that ethnicity (defined as particular shared cultural characteristics) is not likely to influence unduly the emergence of dementia in individuals. Cultural factors may protect against dementia, impeding its recognition and influencing its course and these deserve further investigation. Ethnicity is a general concept that subsumes and conceals the impact of migration, education, health beliefs and socio-economic status on health, and therefore is problematic. Empirical research on dementia and ethnicity reveals that intra-ethnic group variation is greater than inter-ethnic group variation; supporting the view that ethnicity as a category may not have great explanatory power and may foster a category fallacy. However, the experiences of people with dementia and their carers show that the important issues for service providers to consider are language, religious belief and observance, cultural practices (including food and personal care practices) and social support and coping mechanisms. In this position paper we argue that these issues are applicable to all individuals with dementia, independent of apparent ethnicity, and that promotion of cultural competence in service provision should not be relegated to an ethnic minority agenda. The task for health and social care providers is therefore to recognise the diversity of users and to increase access to appropriate quality mainstream person-centred services, rather than to develop segregated or specialized services.

Stigma, racism or choice. Why do depressed ethnic elders avoid psychiatrists?

BACKGROUND

Knowledge of mental health service users views is important in service planning, to ensure access for everyone and in particular for those in minority groups. Depression is common in older people and it has been suggested that ethnic elders may be more vulnerable to mental illness. This study therefore explored and compared the views of White British (WB) and Black African-Caribbean (BC) older people on depression as an illness, avenues of help and the place of mental health services.

METHODS

A qualitative analysis of semi-structured interviews using vignettes describing an older man with depression and a woman with psychosis. The purposive sample consisted of 40 WB and BC older people half of who had been depressed.

RESULTS

21 WB (10 depressed and 11 not depressed) and 19 BC (10 depressed and 9 not depressed) were interviewed. Most people irrespective of ethnicity or depression recognised that there was something wrong with the man with depression. Most did not consider it an illness. Ethnicity but not depression effected the interpretation of the aetiology of the symptoms. A minority thought that consulting the GP would help but some BC specified that it would be inappropriate. BC who had not been depressed thought that spiritual help was appropriate. Both ethnic groups suggested that mental health services were for care, incarceration or dealing with violence. None of those who had been depressed thought that the mental health services were for dealing with violence.

LIMITATIONS

We interviewed established BC immigrants and our results might not apply to new BC immigrants or other immigrant groups. Descriptions within the vignettes of depression and psychosis were defined by us.

CONCLUSIONS

Most older people do not view depression as a mental illness. Older people, particularly BC therefore often do not see psychiatric services as appropriate and believe they are primarily for psychosis and violence. These views are amenable to change. Doctors should be explicit that services are for people with depression.

The distribution of Mini-Mental State Examination scores in an older UK African-Caribbean population compared to MRC CFA study norms

OBJECTIVE

to describe normative data for the Mini-Mental State Examination (MMSE) in a UK African-Caribbean population and compare these with norms for white UK-born elders.

DESIGN

a comparison of MMSE data from two cross-sectional surveys.

METHOD

the MMSE had been administered to a community UK African-Caribbean population and scores were compared to norms from the Medical Research Council Cognitive Function and Ageing Study (CFAS). MMSE data were analysed for 248 African-Caribbean participants aged 55-75 and 5379 CFAS participants aged 65-74, without visual or auditory problems. Distributions of scores were tabulated and error rates for individual items compared.

RESULTS

Median MMSE scores were 25 (interquartile range 22-27) for the whole African-Caribbean sample, 24 (22-27) for those aged 65-75 in the African-Caribbean sample, and 27 (25-29) for CFAS. Differences in error rates were specific to particular items: naming the season, serial seven subtraction, phrase repetition, three-stage command, and copying intersecting pentagons. These differences persisted when both samples were restricted to those with statutory duration of education, who were literate and who had worked in non-manual occupations. Normative data are displayed for MMSE scores in both groups.

CONCLUSION

different distributions of MMSE scores between UK African-Caribbean and Caucasian groups can be principally explained by cultural bias in certain items. If the MMSE is to be administered to older African-Caribbean people, specific normative data should be referred to or else a culturally modified version of the instrument should be used.

Surveying older people from minority ethnic groups: an evaluation of a primary care sampling method for UK African-Caribbean elders

There are substantial logistical difficulties in conducting community surveys of minority ethnic group populations. Primary care lists have been identified as an important potential resource but the representativeness of samples derived through this method has received little evaluation. In a community survey of psychiatric morbidity, African-Caribbean people aged 55-75 were identified by practice staff from registration lists for seven primary care teams in south London. The sensitivity of the process was evaluated by contacting a random sample of people whose ethnicity was not known. Participants aged 65-75 (n = 174) were also compared to a similarly aged group sampled through household enumeration (n = 34) with respect to demographic factors, risk factors for vascular disease, depression and cognitive function. For those with correct addresses, the identified group was estimated to include 72% of the potentially eligible population. Only 8% of contacted people were found not to be eligible in terms of ethnicity. Compared to the household enumeration sample, the primary care sample had marginally higher socio-economic status but was similar with respect to all other measured characteristics. Primary care list sampling with staff-assigned ethnicity therefore appeared highly specific, reasonably sensitive, and did not seem to introduce substantial bias for this population.

Mental health of migrant elders--the Islington study

BACKGROUND

In the UK, 6% of those aged 65 years and over were born abroad, most of whom now live in inner-city areas. It has been suggested that ethnic elders are particularly vulnerable to mental illness.

AIMS

To compare the prevalence of dementia and depression in older migrants with those born in the UK.

METHOD

A cross-sectional community study of 1085 people aged 65 years or older in an inner-London borough.

RESULTS

Compared with those born in the UK, the prevalence of dementia was raised in African-Caribbeans (17.3%, relative risk=1.72, Cl=1.06-2.81) and lower for the Irish-born (3.6%, relative risk=0.36, Cl=0.17-0.87). All those of African-Caribbean country of birth were significantly younger (P=0.000) but no more likely to be taking antihypertensive drugs. They were no more likely to report having cardiovascular problems but had increased rates of diabetes (P<0.0000). The overall prevalence of depression was 18.3% (95% Cl=16.1-20.7). The highest prevalence rate was found among those born in Greece and Turkey (27.2%, Cl=17.9-39.6). Migration per se does not appear to be a risk for depression and dementia in this population.

CONCLUSIONS

The excess of dementia may be of vascular aetiology. There is the potential for primary or secondary prevention.

Cognitive function in UK community-dwelling African Caribbean elders: normative data for a test battery

Many 'first generation' African Caribbean residents in the UK have now reached ages where risk of cognitive impairment and dementia starts to increase. In addition, conditions which may impair cognitive function, such as hypertension, diabetes and stroke, have high prevalence rates in African Caribbean populations. However, there is a lack of normative data for cognitive tests in this ethnic group. Cognitive assessment was carried out in a south London community population of 285 African Caribbean participants aged 55-75 years. Tests were drawn principally from the consortium to establish a registry for Alzheimer's disease (CERAD) battery (Boston Naming Test, verbal fluency, word list recall, and Trailmaking Tests A and B) and also included orientation items from the Mini-Mental State Examination (MMSE) and the Clock Drawing Test. Independent effects of age, sex, education and occupation were identified on scores for most but not all cognitive tests. Compared with normative data for African American populations, lower scores on verbal fluency and the Boston Naming Test were observed but scores on memory tests were comparable. Normative data for the tests are presented, stratified by level of education.

Cognitive function in UK community-dwelling African Caribbean and white elders: a pilot study

In recent years there has been interest in risk of cognitive impairment and dementia in populations of African origin. Little is known about this risk in older African Caribbean residents in the UK. One difficulty is lack of consensus over an adequate cognitive test battery for this community. Forty-five African Caribbean and 45 age and gender matched white community residents were recruited by household enumeration of an inner London electoral ward. These participants were administered the MMSE during a screening interview. Where possible, this was followed up by tests from the CERAD and CAMCOG neuropsychological batteries, a medical examination, and a structured interview with an informant. Based on these data, a psychiatrist blind to ethnicity independently rated 86 of these participants (41 of the African Caribbeans, all 45 of the whites) as cognitively normal, cognitively impaired, or demented. Of 41 African Caribbeans, 18 (44%) were rated as cognitively normal, 9 (22%) were rated as cognitively impaired, and 14 (34%) were rated as demented. Of the 45 whites, 39 (87%) were rated as cognitively normal, 4 (9%) were rated as cognitively impaired, and 2 (4%) were rated as demented. African Caribbeans scored significantly lower than whites in most cognitive test scores, which was not accounted for by their lower educational and occupational attainment, or their higher frequency of cardiovascular risk factors. African Caribbean elders in the UK appear to be at high risk of cognitive impairment and dementia. However, the influence of potential confounding factors such as socio-economic position and ill-health, and the effect of cultural test bias, cannot be ruled out.

Validating screening instruments for cognitive impairment in older South Asians in the United Kingdom

BACKGROUND

The numbers of older South Asians in the United Kingdom are rising. Investigation of their mental health has been neglected compared to their physical health.

OBJECTIVES

This study aimed to determine the sensitivity and specificity of modified versions of two screening instruments for cognitive impairment (Mini-Mental State Examination and Abbreviated Mental Test) in a community-based population.

DESIGN

Two-stage study comparing screening instruments against diagnostic interview.

SETTING

South, central and north Manchester.

SUBJECTS

Community-resident South Asians aged 60 years and over.

METHODS

Subjects were approached via their general practitioners and interviewed at home. Sensitivity and specificity for the screening instruments were calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

For the Gujarati population, the MMSE cutoff was >/=24 (sensitivity 100%, specificity 95%) and AMT>/=6 (sensitivity 100%, specificity 95%). For the Pakistani population, the MMSE cutoff was >/=27 (sensitivity 100%, specificity 77%) and AMT>/=7 (sensitivity 100%, specificity 87%).

CONCLUSIONS

Culturally modified versions of the Mini-Mental State Examination and Abbreviated Mental Test are acceptable and may have a high degree of sensitivity. They may assist with the recognition of cognitive impairment, if an appropriate cutoff is used.

Social determinants of psychiatric morbidity and well-being in immigrant elders and whites in east London

OBJECTIVES

The social conditions under which migrants to the UK live may be more significant than the experience of migration itself in leading to increased risk of mental illness. We aimed to compare the prevalence of mental, physical and social health problems in elderly Somalis, Bengalis and whites living in a deprived inner London area and examine associations between environmental circumstances, social support, physical health status, mood and life satisfaction in these groups. In addition, we wanted to test the hypothesis that differences in mental health between immigrants and whites are explained by social disadvantages rather than ethnicity.

DESIGN

Cross-sectional survey with participants drawn from age-sex registers of general practices, augmented by other sources.

SETTING

East London--'first-generation' Somali and Bengali immigrants and white British.

SUBJECTS

A total of 274 people aged 60+ years: 72 Somalis, 75 Bengalis and 127 whites.

MAIN OUTCOME MEASURES

Symptoms of Anxiety and Depression Scale (SAD), Life Satisfaction Index (LSI). High SAD scores indicate more anxiety and depression symptoms; high LSI scores indicate greater life satisfaction.

MAIN RESULTS

Highest SAD scores were found among Bengalis; lowest LSI scores were found among Bengalis and Somalis. The prevalences of depression (SAD score 6+) were 25% in Somalis, 77% in Bengalis and 25% in east London whites. Physical health status and SAD scores were associated in Somalis (r = +0.31, p < or = 0.01). Bengalis (r = +0.47, p < or = 0.001) and east London whites (r = +0.27, p < or = 0.01). Physical health problems also related to lower LSI scores in Somalis (r = -0.24, p < or = 0.05) and east London whites (r = -0.24, p < or = 0.01). Social factors (i.e. poor housing conditions, low family support and reported need of community services) were strongly associated with SAD scores among Somalis (r = +0.5, p < or = 0.001) and, to a lesser extent, among Bengalis (r = +0.33, p < or = 0.01). Ethnicity (i.e. being an immigrant as opposed to a non-immigrant) became a statistically non-significant risk factor for high SAD scores after adjusting for the effects of age, weekly income, physical health and social problems (OR = 0.71, 95% CI = 0.5-1.1, p = 0.09). A residual, but much attenuated effect for ethnicity on LSI scores persisted in the estimated model after controlling for the same set of independent risk factors (OR = 0.7, 95% CI = 0.4-1, p = 0.05).

CONCLUSION

The marked variation in mental health between ethnic groups in east London might be a reflection of socioeconomic and health differentials acting concomitantly and adversely. Inequalities in housing, social support, income and physical health status accounted for variation in mood observed between immigrants and whites, and may partly explain differences in life satisfaction. These results seem to support a 'multiple jeopardy' theory of ageing in ethnic minorities in east London. Greater efforts are needed to recognize anxiety and depression in immigrant elders. Better social support and housing among 'minority ethnic' elders who live alone might be expected to alleviate social stress and improve mental health and psychological well-being.