File Name: mental disorders in older adults fundamentals of assessment and treatment .zip
Contemporary Perspectives on Ageism pp Cite as. Though it is generally acknowledged that older adults are underserved in the area of mental health services, the impact of ageist stereotypes on mental health diagnosis and access to care, and on the provision of psychotherapy to older adults, has not been extensively studied.
This chapter reviews the sparse literature on ageism and mental health services with the goals of examining current practice related to the assessment of mental health problems and barriers to optimal therapy of older adults from the social perspective of ageism. The chapter begins with a review of literature pertaining to attitudes of mental health clinicians towards psychotherapy of older adults, and focuses on possible contributing factors to the development of ageist attitudes among clinicians.
We also address challenges and problems in the assessment and diagnosis of older mental health patients, and raise the possibility that ageist attitudes may be responsible for some of these issues. Finally, we discuss common difficulties in providing therapy to older adults with mental health problems and review different therapy approaches with older adults.
Here again, we discuss the possibility that ageist attitudes might play a role in difficulties with the adaptation of these therapeutic methods for older adults. The chapter concludes with a discussion of possible prevention strategies to address ageist attitudes in mental health settings and makes recommendations regarding future research in this understudied area.
As mental health clinicians, we strive to meet, treat, and be with our patients through their own experiences, tribulations, and personal journeys. However, when a psychotherapist for example, a social worker, a psychologist, or a psychiatrist encounters an older patient, he or she may be subject to ageist judgements which stem from a stereotypical view of older adults in general, regardless of how the individual patient presents him or herself.
Ageism in the form of age discrimination and age stereotypes is considered a domain-specific phenomenon see Voss et al. A lot has been written in general about ageism in the domains of health care systems and long term care see the chapters in this volume by Wyman et al.
However, less has been published about ageism in the domain of mental health. Nevertheless, a number of studies over the last three decades have demonstrated the existence of negative attitudes toward older adults among psychotherapists.
For example, Dye found negative views regarding the ageing process, and a preference against working with older patients, in a large sample of clinical and counseling psychologists in the USA. Older persons were described by the psychologists as being rigid, as having difficulties in learning new material, and as lacking the required energy and resilience for therapeutic growth. Two other studies eliciting assessments of standardized case vignettes from psychiatrists Ford and Sbordone , and from licensed clinical psychologists in the U.
A Ray et al. In Australia, Helmes and Gee presented psychologists and counselors with a vignette describing a fictitious case, and found that an older patient was rated as less able to create proper therapeutic relationship, as having a poorer prognosis, and as being less appropriate for therapy compared with a younger patient with the same symptoms.
More recently, a review demonstrated an age bias among psychotherapists, with many expressing the view that depression in late life is a natural consequence of old age and that old age is a phase of life associated with less satisfaction and diminished personal growth Laidlaw and Pachana An urgent issue which emphasizes the existence of negative attitudes toward older adults among psychotherapists concerns the legitimacy of suicide in older adults. Uncapher and Arean found that USA physicians were less interested in treating older adults with suicidal tendencies than they were in treating younger patients with identical problems.
Hence they were less willing to use therapeutic strategies to address suicidal thinking in older patients. In another study Barnow et al. Here, too, health professionals working in psychiatric institutions expressed less willingness to treat older compared to younger suicidal patients. These biases against older patients appear to be formed well before mental health clinicians enter the professional world.
A survey of clinical psychology trainees Lee et al. Many of the trainees believed that psychotherapy was problematic in this age group due to cognitive problems, such as difficulties with memory The psychotherapists also identified other challenges to working with older patients, such as a decline in hearing Curriculum content in mental health training programs has traditionally been lacking in material related to geriatric patients and in clinical skills for working with the older population e.
Subsequent professional work experiences often do not allow for adequate exposure to older patients. For example, data on the current major fields of APA members in show that only health services providers out of 43,, reported Geropsychology as their main area APA Center for Workforce Studies reported in American Psychological Association In the UK, similar figures were reported Bryant and Koder As a result, many mental health professionals report a lack of specific knowledge about psychopathology and psychotherapy with older adults.
For example, in Britain, trainees in psychotherapy expressed a lack of information about psychotherapy with older adults Scott and Bhutani , and recruiting psychologists to work with older adults has been challenging e. American psychologists reported minimal formal education in geropsychology and endorsed the need for additional training Qualls et al. Another study in Britain Richards et al. This study found that the practitioners lacked essential theoretical and research-based knowledge in the field of ageing and old age; rather, they primarily made use of common organizational policies and personal experience with ageing family members to analyze a clinical vignette presented to them.
In summary, the lack of knowledge and training in geriatric care, especially in the field of clinical psychology, presents a global problem, in particular in the context of demographic trends toward an increase in the aged population.
Lack of specialized geriatric knowledge was found to be an influential factor in the negative attitudes of psychologists toward older adults Koder and Helmes This problem begins at the undergraduate psychology education level, as most courses do not include content on the psychology of old age, and continues through the advanced training of clinical psychologists specializing in geriatric care Bryant and Koder ; Qualls et al.
Therefore, clinical exposure to the aged has frequently been suggested as a means to mitigate pre-existing negative stereotypes concerning older adults Bryant and Koder ; Koder and Helmes Nevertheless, the factors underlying age-based bias in mental health care are numerous.
Research suggests that an additional reason for these attitudes among clinicians may be the way elderly patients internalize ageist social stereotypes, and how the patients themselves perceive their psychiatric problems Laidlaw and Pachana In the next subsection we will change our perspective from the psychotherapist to the patient, discuss self-ageism among older mental health patients, and elaborate on the effect of self-ageism on the encounter between older mental health patients and clinicians.
One out of five persons above the age of 65 suffers from some form of mental illness e. The majority of these older adults prefers to consult a primary general practitioner and does not seek out mental health clinicians Lerner and Levinson Unfortunately, primary general practitioners encounter barriers to the management of mental illness both at the individual and the system levels Ayalon et al.
But more importantly, when referrals to mental health practitioners are made, older adults are unlikely to follow through on these referrals, and thus further assessment often does not occur DiNapoli et al. When older adults relate to a social group which may be discriminated against, based on their skin color, race, gender, or being a cultural minority see Krekula et al. This may also be the experience of older adults who suffer from mental health problems. Self-double stigmatization may have a negative effect on the ability of older adults with psychiatric conditions to seek help from mental health professionals.
Studies have shown that internalized stigma related to mental illness e. Several researchers have examined double stigmatization associated with depression in old age. Depression is a stigmatized illness and may be seen as a sign of personality weakness and as something to hide.
Therefore, there are societal negative attitudes toward depressive patients e. It has been suggested that negative attitudes towards depressive patients harm self-esteem and can worsen symptoms Fung et al. In addition, negative self-perceptions of ageing are associated with increased depressive symptoms in later life e.
Two cross-sectional studies have pointed to the link between more positive attitudes toward ageing and less depression Bryant et al. Moreover, a recent study of over older military veterans in the U. Group differences were found in rates of suicidal ideation Whereas higher negative self-perceptions of ageing are associated with more severe psychopathology, double stigmatization further impedes the tendency of older mental health patients to seek help from mental health professionals e.
Several researchers have suggested that the underutilization of mental health services by older adults may result from the internalization of ageist attitudes by older patients Levy Consequently, the difficulties that older patients experience in mental health treatment likely increase as their mental condition persists or even worsens as a result of their inability to receive help.
When trying to understand the mechanisms responsible for the association between negative self-perceptions of ageing and proneness to severe psychopathology, ageism can be identified as a stressor in its own right. Following this line of thought, people who hold negative attitudes toward their ageing may be less willing to take part in positive social activities Weiss and Lang , and may hold negative images of age-related health problems.
In contrast, positive attitudes toward ageing may act as a buffer against mental distress, as older adults with more positive attitudes toward ageing seem to become more involved in healthier ways of living, such as maintaining a nutritious diet Huy et al.
There is also empirical evidence indicating that ageism is associated with heightened ageing anxiety Bodner et al. These concerns act as stressors that increase sensitivity to physical symptoms Poon and Knight , and become associated with higher levels of depression during midlife Barrett and Robbins , as well as with other symptoms of mental distress Bodner et al. Of note, these findings are also consistent with the behavioral model of late life depression Fiske et al. In summary, older adults with mental health problems may hold both ageist negative attitudes toward themselves as well as negative attitudes toward mental illness.
This self-double stigmatization may have an impact on their symptoms and their interactions with the mental health care system.
Following this line of thought, in the next subsection we will discuss the objective difficulties clinicians face when diagnosing mental health problems in older adults. Then, we will examine how ageist attitudes of both clinicians and patients may impact the accuracy of several mental health diagnoses and subsequent treatment recommendations. For a number of reasons, the assessment of mental health disorders in older adults can be complex and often requires a high level of expertise, effort, and time.
In old age, there is an overlap between some psychiatric symptoms and symptoms related to changes in hormone levels Sternbach , declines in cognition Petersen , physical disability Milaneschi and Penninx , and physiological processes McKinney and Sibille These non-psychiatric symptoms are often part of normal ageing. For example, needing less sleep, changes in diet and digestive functioning Elsner , reduction in energy, and slowed information processing are considered normal age-related changes Whitbourne and Krauss However, these symptoms can also be part of the clinical presentation associated with common disorders such as anxiety or depression Fiske et al.
Teasing apart the etiology or multiple etiologies of such symptoms can be very challenging when working with an older patient. Another challenge to accurate diagnosis of mental health problems in older adults lies in the limitations of available psychiatric assessment tools.
Mental health symptom questionnaires and interview instruments have been criticized for inadequately discerning between age-related problems and psychiatric symptoms Eisner et al. Despite the fact that many scholars have studied this issue and considered potential solutions e. Moreover, as noted above, many mental health clinicians have not received adequate basic education in geriatric mental health and thus may experience additional challenges in providing assessment and treatment for complicated older adult cases Halpain et al.
A further issue concerns the clinical presentation of mental disorders. Clinicians and researchers have long reported age differences in symptom constellation of some mental disorders, such as depression see Blazer and Hybels and PTSD Palgi ; Pietrzak et al. However, age-based comparisons of symptom presentations have found mixed results e. The mixed results in the literature have not helped to decrease clinician bias and confusion in this domain.
Adding to this is the mounting evidence that subthreshold mental disorders are more prevalent than diagnosed disorders in late life and are associated with significant disability and comorbidity e. Together, these factors make the diagnosis of mental disorders in old age more difficult. However, when the etiology of the symptoms is unclear, such attributions may further complicate the clinical picture.
Research suggests that older adults with depression may tend to blame themselves and their lifestyle choices for their own medical symptoms, while making different attributions for the same symptoms in others Benedict They may attribute physical symptoms for example, fatigue, concentration problems, and weight loss to medical diagnoses and not to psychiatric conditions, which may affect responses on self-report mental health measures and in interview-based assessments.
It can be difficult for both patient and clinician to identify impaired functioning when a retired or disabled older adult has few social roles or formal responsibilities Hendrie et al. Further, willingness on the part of older adults to admit impairment may be related to ethnicity or cultural values e. Apesoa-Varano et al. To sum, the interaction between age-related changes and the clinical phenomenology of psychiatric problems in old age makes it more challenging and time-consuming for patients and clinicians to accurately perceive and diagnose psychiatric conditions.
It can be especially problematic when these objective difficulties in diagnosing psychiatric syndromes in late life are combined with stereotypes based on age, in both patients and clinicians.
In this subsection we discuss four specific psychiatric syndromes which can be difficult to diagnose in old age.
Intended for the mental health practitioner, the book translates research findings into information to be applied in practice. It recognizes diversity as extending beyond race and ethnicity to reflect characteristics or experiences related to gender, age, religion, disability, and socioeconomic status. Individuals are viewed as complex and shaped by different intersections and saliencies of multiple elements of diversity. Chapters have been wholly revised and updated, and new coverage includes indigenous approaches to assessment, diagnosis, and treatment of mental and physical disorders; spirituality; the therapeutic needs of culturally diverse clients with intellectual, developmental, and physical disabilities; suicide among racial and ethnic groups; multicultural considerations for treatment of military personnel and multicultural curriculum and training. Practicing clinicians and counselors, and researchers in clinical psychology and sociology. Psychologists, social workers, licensed professional counselors, psychiatrists and cross-cultural researchers. Chapter 6.
Contemporary Perspectives on Ageism pp Cite as. Though it is generally acknowledged that older adults are underserved in the area of mental health services, the impact of ageist stereotypes on mental health diagnosis and access to care, and on the provision of psychotherapy to older adults, has not been extensively studied. This chapter reviews the sparse literature on ageism and mental health services with the goals of examining current practice related to the assessment of mental health problems and barriers to optimal therapy of older adults from the social perspective of ageism. The chapter begins with a review of literature pertaining to attitudes of mental health clinicians towards psychotherapy of older adults, and focuses on possible contributing factors to the development of ageist attitudes among clinicians. We also address challenges and problems in the assessment and diagnosis of older mental health patients, and raise the possibility that ageist attitudes may be responsible for some of these issues. Finally, we discuss common difficulties in providing therapy to older adults with mental health problems and review different therapy approaches with older adults.
Depressed older adults are more likely to be seen in primary care than in specialty mental health settings, but research shows that physicians may not routinely screen for depression. Other clinical disciplines are also in a position to screen for depression, but have not been studied. We used a cross-sectional, online survey with experimental manipulation of vignettes. Participants were trainees in medicine 83 , psychology 51 , nursing 49 , and social work Lower time pressure and greater symptom severity increased likelihood of screening.
Since , 12 primary empirical studies have been published addressing PDs in older adults; 3 addressing epidemiological aspects, 6 on assessment, 2 exploring both epidemiology and assessment, and 1 examining treatment. PD research in older adults is steadily growing and is predominantly focused on assessment. The studies showed that PDs were rather prevalent ranging from Furthermore, schema therapy seems to be a feasible and effective intervention. Despite promising findings, there is an urgent need for studies addressing PDs in older adults, especially studies investigating epidemiological aspects and treatment options.
Metrics details. Evidence about the effectiveness of psychosocial interventions to reduce the incidence of depression and anxiety and promote subjective well-being in older people is limited, particularly in Latin-American countries. This study thus aims to assess a program specifically designed to address this issue in persons aged 65 to 80 and attending primary health care centres. Older people who use primary care centres are to be randomly assigned to the program or to a control group. The program is group based; it includes cognitive stimulation, expansion of social support networks and cognitive behaviour strategies.
- Мужская комната оказалась закрыта… но я уже ухожу. - Ну и проваливай, пидор. Беккер посмотрел на нее внимательнее. К ней как-то не шло сквернословие - как неуместны сточные воды в хрустальном графине. Но, приглядевшись, он убедился, что она вовсе не такая изысканная особа, как ему показалось вначале. Веки припухли, глаза красные, левая рука у локтя - вся в кровоподтеках с синеватым отливом. Господи Иисусе, - подумал .
Уничтожение банка данных АНБ - акт агрессии, на которую, была уверена Сьюзан, Танкадо никогда бы не пошел. Вой сирены вернул ее к действительности. Она смотрела на обмякшее тело коммандера и знала, о чем он думает. Рухнул не только его план пристроить черный ход к Цифровой крепости. В результате его легкомыслия АНБ оказалось на пороге крупнейшего в истории краха, краха в сфере национальной безопасности Соединенных Штатов.
- Стоп. - И быстро пробежала глазами информацию. Здесь имелась масса всяческих сведений.
Чем могу помочь? - спросила она на гортанном английском. Беккер не мигая смотрел на эту восхитительную женщину.