Addressing Barriers within Elderly Populations
Reprinted from "Seniors' Mental Health" issue of Visions Journal, 2002, No. 15, pp. 7-8
Depression is one of the most common emotional disorders in the elderly population. In Canada, it is estimated that depression affects approximately ten per cent of this population.1 The prevalence rates of depression among visible minority elders, such as the elderly Chinese, have not been well studied; however, it is believed that similar prevalence rates apply across cultures. There are a number of barriers to the detection and treatment of depression in cross cultural elderly populations. For this reason, depression in ethnic minorities is largely under-reported and under-diagnosed. In a country where minority populations continue to grow, it is of significance to address some of the difficulties that these individuals and their caregivers are faced with.
Detection of depression in elderly minorities may be difficult for a number of reasons. In some cultures, depression may be under-diagnosed because of alternate patterning or presentation.2 In Chinese societies, metaphors such as “heartache” — conveying sadness — and “fatigue” or “tiredness” — conveying hurt and despair — are examples of how complaints of emotional distress may be expressed in a culturally acceptable manner.3 In some cultures, it is more socially acceptable to seek help for physical complaints (somatization) than it is for psychological complaints.
The term neurasthenia is Greek for “lack of nerve strength” and was introduced into China in the early 1900s. Since then, the term has been used by the Chinese to account for a wide array of symptoms including physical symptoms (such as fatigue and insomnia), cognitive symptoms (such as poor memory) and emotional symptoms (including symptoms of depression).2 Neurasthenia has been used as a culturally acceptable diagnosis that is considered distinct from diagnoses of psychiatric illnesses. In fact in 1982, Kleinman observed that 87% of neurasthenic patients in Hunan could be reclassified as having “major depression” according to psychiatric diagnostic criteria.4
Another barrier to the detection of depression is the stigma often associated with mental illness. Patients may be too ashamed to seek help for fear that they will no longer be accepted by society. Additionally, they may fear bringing shame to their families. In other instances, it may be the family who fears the implications of having one of its members affected by mental illness and the collective loss of face for the extended family. They may treat the illness as a secret, or deny that the person has a mental illness at all and thus delay seeking medical intervention until they can no longer cope, or until they have exhausted all of their family resources.
The difficulty in diagnosing depression in the elderly is further compounded by the high prevalence of concurrent illness and the use of multiple medications in this population. Both physical and emotional symptoms are often too easily attributed to underlying medical conditions, side effects of medications, or in cases of multiple medication use, drug interactions, making diagnosis of depression difficult.
In addition to the barriers affecting detection of depression, there are also a number of barriers to effective treatment. One of the major barriers to treatment is traditional disbelief in or reservation about Western medical practices. Many ethnic minorities have strong beliefs in their own traditional healing practices, which has an impact on both their willingness to try or seek out other methods of treatment, and on the likelihood that they will comply with prescribed treatment plans. For example, in many Asian cultures, talking about problems is not considered appropriate treatment for emotional illness. From that perspective, it is easy to understand why many of these people from this background would question the use of psychotherapy as a form of treatment.
In Chinese cultures, it has been suggested that a further barrier to the treatment of depression may be an increased tendency to “accept depression as a way of life.” Cultural concepts such as mingyun (fate or destiny) may play a role in the Chinese because they believe a life of stress and hardship was predetermined for them.2 Additionally, sociocultural factors such as a long-standing tradition of withstanding hardship in combination with culturally valued personality traits such as stoicism and tolerance may discourage help-seeking behaviours, and indeed signify character weakness in those who seek out help.2
Treatment may also be affected by cultural variability seen in drug metabolism, response to treatment, and side effect profile. For example, 33% of Asian-Americans have genetic variations in their liver enzymes such that they have lower levels of activity of these enzymes, compared to less than ten per cent of Caucasians.5 It is therefore often necessary to start an antidepressant at half of the initial recommended dose and titrate slowly upwards [that is, making small dose increments to find the least amount of medicine that will produce a desired effect], according to clinical response in patients from these ethnic groups.
From a cross cultural standpoint, patients are less likely to feel at ease discussing their personal concerns with a caregiver from another culture that they perceive as unlikely to understand their circumstances or cultural beliefs, even when there is no significant language barrier. At Vancouver General Hospital (VGH), efforts have been made to improve access to ethnocultural mental health through a Cross Cultural Psychiatry Outpatient Program that was established in 1988. The program provides patients with “ethnic-matched” psychiatrists who work to assess, treat and coordinate resources for patients in a culturally sensitive manner.
The VGH clinic has proven to be a useful resource for many ethnic patients, and demonstrates a positive step towards improving utilization of mental health services. Psychoeducation may be of great value in educating the public about different psychiatric disorders as well as helping to de-stigmatize mental illness. Increasing awareness of traditional beliefs, social stigmas and sociocultural acceptances will also help both ethnic and non-ethnic health care practitioners to provide care that is culturally sensitive. The development and distribution of culturally sensitive psychoeducational pamphlets might also help to facilitate the recognition, diagnosis and treatment of psychiatric disorders in different ethnic minorities. In addition, research in the areas of inter/intra-ethnic differences and inter-generational differences will also be valuable. Many ethnic groups are assumed to be homogeneous as a population when in fact there may be substantial within group diversity and variation. Identification of these intracultural differences will further enhance utilization of mental health resources.
About the authorsHiram is a Consultant Psychiatrist at Vancouver General Hospital; Kimberly is a medical student at the University of British Columbia
McEwan, K.L., Donnelly, M., Robertson, D., & Hertzman, C. (1991). Mental health problems among Canada’s seniors: Demographic and epidemiologic consideration. Ottawa: Mental Health Division, Health Services and Promotion Branch, Department of National Health and Welfare.
Parker, G., Gladstone, B., Chee, K.T. (2001). Depression in the planet’s largest ethnic group: The Chinese. American Journal of Psychiatry, 158, 6.
Chang, W.C. (1985). A crosscultural study of depressive symptomatology. Culture, Medicine & Psychiatry, 9, 295-317.
Kleinman, A. (1982). Neurasthenia and depression: A study of somatization and culture in China. Culture, Medicine & Psychiatry, 6, 117-190.
Canadian Network For Mood And Anxiety Treatments. (2001). Clinical guidelines for the treatment of depressive disorders. Canadian Journal of Psychiatry, 46 (supplement 1), 73S.