‘I feel I am treated differently because of my age. It feels like I’m invisible now and I think sometimes I don’t get offered services because I’m old.’

Age discrimination remains the fundamental barrier to improving services and support for older people with mental health problems. This is the conclusion of the independent UK Inquiry into Mental Health and Well-Being in Later Life, which published it’s second and final report in August 2007. Some attempts to eradicate direct discrimination have assumed that there is no justification for any specialist services for older people – they have moved immediately to indirect discrimination. The Inquiry recognises the need for specialist services for some older people but calls for greater clarity on what these services offer and to whom.

The Inquiry, which was established in 2003 and has been supported by Age Concern since its inception, was created because of concern about the neglect of mental health in later life, which often falls through gaps between policies and services for ‘mental health’ and ‘older people’.

The first report, published in 2006, focused on the promotion of good mental health and well-being for all older people. The second report concentrates on services and support for older people with mental health problems and has been developed from a literature and policy review, fieldwork with older people and their carers, evidence from organisations and professionals, and the expertise of an independent board, advisory group and government participants.

The prevalence of depression warranting some level of intervention is so great – affecting one in four older people in the community – that the Inquiry calls for a public health approach to tackle this problem. Since the risk factors for depression in later life are well known, far greater emphasis is needed on prevention through both the reduction of risk factors and minimisation of their impact, together with programmes to target individuals at times of risk, particularly at transition points.

Through an extensive review of literature and policy, the Inquiry found that the views and experiences of some older people with mental health needs were either absent or under-researched. These included people growing older with long-standing mental health problems, some of whom suffer the consequences of discriminatory policies and practice which mean that they are required to leave services they have grown accustomed to on or around their 65th birthday, whether or not their needs have changed. Although older men and women have some of the highest rates of suicide in the population, they have tended to be marginalised in suicide prevention strategies. And despite the fact that alcohol and drug misuse have a significant impact on the lives of older people, there is little research into the scale of these problems and few services to support those affected.

For the most part, older people with mental health problems live in the community and manage without the help of any formal services or support. Older people who contributed to field work commissioned by the Inquiry described their coping strategies; some placed great reliance on family, friends and neighbours and described the benefits they drew from talking to people who were experiencing similar problems. The Inquiry emphasises the need to build on and reinforce these sources of support and, in particular, to provide easily accessible information and advice, along with advocacy for those who need it.

When older people do turn for help to statutory services, GPs are often the first (and frequently the only) point of contact and therefore hold an enormous responsibility to identify and respond to older people’s mental health needs. They also play a pivotal role in the coordination of care. GPs recognise the importance of this role but practice often does not reflect this. Mental health problems amongst older people are vastly under-diagnosed and under-treated. Only half of older people who need treatment for depression receive this – and often from a much narrower range of options than are available for younger adults. Fewer than half of older people with dementia are diagnosed by GPs. Older people with sensory impairments, older men and older people with lower levels of educational attainment are those most at risk of having their mental health needs overlooked.

Although GPs and other primary care professionals have a lead role, the Inquiry highlights other types of service which are often important. The contribution of housing is often overlooked and there is a call for housing strategies to recognise the role that housing plays in supporting older people with mental health problems. At the same time, social care should be playing a key role in preventing mental health problems and supporting people to participate in society. The tightening of eligibility criteria, however, means that the potential contribution of social care is often unrealised and it is in social care that the strict demarcations between mental health services for ‘adults of working age’ and those for ‘older people’ have become most entrenched.

In terms of settings, acute hospitals (where up to 60% of older people experience mental health problems) and care homes merit special attention. The mismatch between the knowledge, education and training of staff and the needs of the population they serve requires urgent attention. The Inquiry calls for system-wide reform of the care home system, given that mental health problems are so common as to be almost universal.

The development of the workforce, including through education and training, needs to be accompanied by organisational development and capacity building, and additional investment in services and support for older people with mental health problems. The Inquiry calls for strong political, professional and societal leadership to drive through the changes which are required.

There are 35 recommendations made by the Inquiry including:

• a call to national Governments to establish a high-level task force to coordinate and drive the development and improvement of services;
• the introduction of a duty on public bodies to promote age equality;
• a Commission for Equality and Human Rights Inquiry into equality and human rights in mental health services (including age equality);
• inclusion of older people in anti stigma and public mental health campaigns;
• further research into the overlooked areas of older people’s mental health;
• amendments to the GP contract to incentivise the identification and treatment of depression;
• local comprehensive commissioning strategies for mental health to include older people and specialist services;
• provision of flexible home care which offers both emotional and practical support at an early stage; and
• inclusion of assessment and management of older people’s mental health needs in all basic training courses in health, social care and housing.

The scale of the problem is vast and the extent to which these issues have been neglected is hard to overstate. Yet the Inquiry remains positive that change can and will happen. It sets out a vision of a society in which the needs of older people who experience mental health problems, and the needs of their carers, are understood, taken seriously, given their fair share of attention and resources, and met in a way that enables them to lead full and meaningful lives. The Inquiry believes that this is achievable and that this achievement will benefit society as a whole.

The full report from the Inquiry, executive summaries and background papers can be found at www.mhilli.org