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Helen* describes moving into an aged care residence last year as “a very sudden trauma”.
There’s nothing wrong with the institution itself or the people there – both are “very nice”, Helen, a 90-year-old former clinical psychologist, tells ABC RN’s Life Matters.
“But it’s not home,” she says.
“Moving from a two-bedroom unit into a one-room home is really quite confronting … I’d left behind my furniture, many of my clothes, my keepsakes, my books.
“[There] was a terrible sense of abandonment, of grief, of loss, of having left behind my personhood, my independence and my ability to make decisions for myself.”
Helen experienced depression after moving to the aged care residence, and she’s noticed others there displaying “various signs of depression”, too.
“There are many people who sit quietly and cry for days after they arrive,” she says.
“I see it every day here.”
Helen and her co-residents are part of a cohort of Australians facing some of the highest risks of depression in the country.
“Currently, around half of all aged care residents have substantial symptoms of depression,” says psychologist Tanya Davison, the lead researcher of a new study, published by the government’s National Health and Medical Research Council (NHMRC), into psychological therapies in aged care.
“That’s about four times higher than the rate that we see in the general population of older people,” she says.
“And six in 10 people living in aged care at the moment are prescribed an antidepressant medication.”
It’s an approach that’s “clearly not” working, Professor Davison says.
Alternatives that have been shown to improve mental health outcomes do exist. So why aren’t they more widespread?
Why the high levels of depression
Multiple factors put people entering aged care at risk of depression, Professor Davison explains.
“People with complex medical conditions, people who’ve experienced a loss or bereavement, people who may have cognitive impairment or dementia [or] frailty – all of those factors are the reasons why people require aged care, but they’re also important risk factors for depression.”
Another big problem is the way many older people make the move into an aged care residence.
“That’s very difficult for many people,” Professor Davison says.
“It’s often not well planned. Often people have very limited time or input into their relocation and that’s associated with poor adjustment to aged care.”
Day-to-day life in residential aged care presents further risk factors, including social isolation and loneliness.
“[People] have been removed from their communities and previous sources of social engagement. They often report feeling bored, that they don’t have activities to do [that are] personally meaningful for them,” Professor Davison says.
“It’s not uncommon to see people just sitting in their room staring at a television for much of the day.”
Therapy works
When she moved into aged care, Helen felt surrounded by strangers and struggled to find someone to talk to.
“It’s very hard to find any sort of shared history among the people that you’re with. And I found that really difficult,” she says.
She enlisted and paid for support from her own psychiatrist, and she says it was very helpful to “give expression to some of the grief and loss that have been part of what’s overcome me”.
She says she’s now “come though” the depression since initiating sessions with the psychiatrist.
Professor Davison says the recent study into psychological therapies in aged care, which included reviewing randomised trials with 873 older people with depression, echoes Helen’s experience.
“It showed people who had had access to psychological therapy had less depression than people who receive just the usual care approaches,” she says.
Sunil Bhar is the director of Swinburne University’s Wellbeing Clinic for Older Adults support service and a co-author of the NHMRC study.
He says, while there were limitations to the study, including that the “methodological rigour wasn’t as strong” in some historic research that was reviewed, the message to emerge from it is clear.
“Psychological therapies were much more effective than usual care … We absolutely need to be offering more therapies,” he says.
“We know from this review and the experience that we’ve had over decades, psychological therapies do work.
“The review that we’ve conducted found that between two and 12 sessions might be sufficient to bring up an improvement, and that speaks to the feasibility of this particular approach.”
What’s the hold-up?
There are several reasons why psychological therapy isn’t more accessible to older people.
One is funding.
“For a long time, people living in residential aged care didn’t have access to the same funding to receive psychological therapy as others. And there’s still a disparity there around funding,” Professor Davison says.
Residents in aged care can access Medicare-subsidised therapy through a mental healthcare plan “only under quite specific circumstances”.
“You need to be referred by a psychiatrist and … unfortunately, very few people have access to a psychiatrist.”
Indeed, between 2012 and 2017, less than 3 per cent of Australian aged care residents with a mental health condition accessed Medicare-funded mental health services, including GPs, psychiatrists and allied health.
“There are some other [mental health] schemes available, but it’s very much at a small scale currently,” Professor Davison says.
“So we do need to look at how we can provide more funding and improve the access.”
Ageism presents another hurdle.
“There’s a misperception out there that older people aren’t interested in psychological therapy; [that] maybe they don’t have the psychological insight or the cognitive flexibility to benefit,” Professor Davison says.
“But of course, this research and lots of research has found that that’s certainly not the case. Psychological therapy is just as effective with older people.”
She argues there’s a need for “better training of the mental health workforce in working with the older population, to increase the pool of specialists available to respond” and that “we also need to look at the skills within residential aged care facilities to detect and respond to residents with depression”.
“The aged care workforce has very poor training in mental health currently,” she says.
‘A desperate need’
Helen wants other aged care residents to have access to the same professional help she sought out for herself.
“I’ve felt very strongly that there is a desperate need for some sort of counselling … for people coming into aged care,” she says.
She believes there should be a national provision of counselling for people both before and after they move into an aged care residency.
She says for residents like her, depression has become normalised.
“It shouldn’t be normal,” she says.
Since the 2018 Royal Commission into Aged Care Quality and Safety, Professor Davison says there is “good awareness of the problem” of mental health among aged care residents.
In 2018 the federal government introduced the Improved Access to Psychological Services in Aged Care Facilities initiative, which Professor Davison says was “highly welcome and a step in the right direction”, but she notes “this is only providing services to around 3,000 Australians per year”.
She says the government is doing a huge amount of work to improve the quality of aged care and maintain staff.
“We’re in a period of major reform right across the whole aged care sector,” she says.
But there are potential shortcomings to that work, Professor Davison says.
“I haven’t seen a lot of focus around mental health.”
She says there are “some indications” that mental health will be a higher priority in the new set of quality standards that the government is currently developing for the aged care sector.
“The detail is not there yet. But, clearly there’s much more of a focus [on mental health] in these new proposed standards than we’ve seen before.
“So I’m hopeful that we’re on the right [path]. What a great opportunity right now, given the major reforms underway, to really get this right.”
The Minister for Health and Aged Care, Mark Butler, and the Minister for Aged Care and Sport, Anika Wells, were approached for comment.
*Last name omitted to protect privacy.
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