Alisoun Milne, Senior Lecturer in Social Gerontology, University of Kent a.j.milne@kent.ac.uk

IMPROVING MENTAL HEALTH & WELL BEING IN LATER LIFE: EVERYBODY’S BUSINESS (INCLUDING YOURS!)OCT 31ST 2008 Alisoun Milne, Senior Lecturer in Social Gerontology, University of Kent a.j.milne@kent.ac.uk

MENTAL HEALTH IN LATER LIFE: WHY EXPLORE IT? • Old age is not a stage of life associated with ‘inevitable decline’ of health • Chronic ill health affects only a minority of older people; much can be done to ameliorate both risks & symptoms • But… defining & conceptualising ‘mental health’ in later life is not straightforward • Its links to the broader constructs of ‘well being’ and ‘quality of life’ are little explored • By illuminating these we may extend understanding of mental health in later life & expose opportunities for promotion

MENTAL HEALTH IN LATER LIFE: IS IT IMPORTANT? • Good mental health is as important in later life as at any other stage of life • Everyone has mental health needs whether or not they have a diagnosis of mental illness • Our mental health has a powerful influence on how we feel & act • … In fact it is central to overall health and well being & has a profound impact on quality of life • Mental health is routinely identified by older people themselves as pivotal to ‘ageing well’ (Bowling, 2005)

MENTAL HEALTH IN LATER LIFE: WHAT IS IT? • Research consistently identifies that: • Having a role; good social relationships with family, friends & neighbours; an adequate income, being physically fit & living in a supportive neighbourhood, are promoting of mental health • Deteriorating health, loss of independence, loneliness, fear of death, living in poor housing & neighbourhood and decreased income are undermining of mental health • The negative impact of losses & physical illness are key risk factors (Godfrey and Denby, 2004) • How well an older person adjusts to late life challenges is a key factor in determining ongoing mental health (Victor, 2005)

MENTAL HEALTH IN LATER LIFE: HOW CAN IT BE DEFINED? • WHO (2003) defines mental health as: ‘a state of well being whereby individuals recognise their abilities, are able to cope with the normal stresses of daily life and make a contribution to their families and communities’ • Older people consider mental health to be characterised by: a sense of well being, the ability to make and sustain relationships, and the ability to meet the challenges and circumstances which later life brings • The Mental Health Foundation views good mental health as the ability to: develop emotionally, creatively, intellectually and spiritually; initiate, develop and sustain mutually satisfying personal relationships; face problems, resolve them and learn from them; are confident and assertive; are aware of others and empathise with them; use and enjoy solitude; play and have fun; laugh, both at themselves and at the world (2006)

MENTAL HEALTH & QUALITY OF LIFE • Considerable synergy exists between those issues that contribute to good mental health and those that promote ‘quality of life’ • QoL is a concept encompassing emotional, social, psychological, and health related, domains - broadly it encapsulates ‘how good’ a person’s life is overall • Recent work identifies the following dimensions as the ‘building blocks’ of QoL: ‘having an optimistic outlook & psychological well being, having good health & functioning; having good social relationships, preventing loneliness; maintaining social roles; living in a neighbourhood with good community facilities & that feels safe; having an adequate income; and maintaining a sense of independence & control over one’s life’ (Bowling, 2005)

MENTAL HEALTH & QoL (2) • QoL is a dynamic & multi-level construct reflecting macro - societal, meso - community, and micro - family & individual, influences • It is also a collection of objective and subjective dimensions which interact together (Lawton, 1991) • Of particular note is the concept of ‘psychological capital or well being’ which subsumes the dimensions of ‘mental health’, ‘life satisfaction’, and ‘self efficacy’ • ‘Self efficacy’ is a particularly important factor in the promotion of mental health: contributes to enhancing ability to adapt to change & challenge (Godfrey & Denby, 2004) • Dovetails with emerging evidence about ‘resilience’ across the life course: underpins ‘disability paradox’

MENTAL HEALTH & SUCCESSFUL AGEING • ‘Successful ageing’ is a concept closely aligned to that of quality of life (Livingstone et al, 2008) • Literature tends to define successful ageing as the ‘avoidance of physical or cognitive impairment’, neglecting the possibility of positive adaptation • Tends to prioritise physical health domains over those related to ‘resilience’, self efficacy or mental health • Whatever the distinctions between QoL & successful ageing concepts are often conflated by older people • In a recent study older people identified ‘successful ageing’ as incorporating: being able to adapt to continuous physical change; engaging in relationships; maintaining independence; having enough money to participate; fulfilling desires and personal objectives; & taking part in meaningful activity (Reed et al, 2003)

Mental health, Quality of life & Successful ageing • There is considerable common ground between the conceptual & theoretical constructs of mental health, quality of life & successful ageing • Whilst ‘mental health’ may be viewed as a narrower construct than its ‘parent’ frameworks, it is an much a product of quality of life as it is a component • Whatever the differences, there is broad agreement that mental health is: an equally important part of QoL as physical health, & is intrinsically bound up with a range of dimensions that both directly and indirectly impact upon it • The next step is to extend understanding about the determinants of mental health, a key stage on the path to improving it (Age Concern, 2007)

DETERMINANTS OF MENTAL HEALTH - RISKS & PROTECTIVE FACTORS • In order to explore the determinants of mental ill health in later life it is useful to draw upon a framework that conceptualises risks to mental health as being located in three broad spheres: Background factors; Stressors; & Protective/Vulnerability factors • Framework illuminates the links between macro level societal factors, meso level community issues & micro level family or individual resources • Also accommodates the life course perspective • Further, building up a coherent understanding of risks & protective factors will help inform the development of strategies to prevent mental ill health & promote mental health

BACKGROUND RISK FACTORS, STRESSORS & PROTECTIVE/ VULNERABILITY FACTORS • Background Risk Factors: • Age, gender & ethnicity • Socio-economic situation • Stressors: • Previous experience of mental ill health • Experience of loss, such as ill health or disability • Specific life events e.g. bereavement • Key points of transition in the ageing process such as retirement • Protective/Vulnerability Factors: • Personal/psychological • Social relationships & social support • Environmental factors

Background risk factors: Socio-economic situation • Living in poverty provokes stress & loss of control over life; it is a specific risk factor for loneliness, depression & exclusion (Victor, 2009) • Being poor reduces an older person’s capacity to make choices, & participate & undermines independence • Two million older people live in poverty in the UK: older women, carers & ethnic minority elders are at particular risk • Conversely, having access to a reasonable income has a positive impact on mental health & well being • Provides the means to take advantage of opportunities to feel safe & supported ,& facilitates social inclusion • Older people with money also tend to live in nicer neighbourhoods & are less exposed to crime and environmental decay • Money can also cushion the effect of loss, EG: the negative impact of a disability may be mediated by access to private treatment or alternative therapy

STRESSORS: LOSS – ILL HEALTH & DISABILITY • Losses accumulate in later life, especially very old age • 26% of people aged 50 to 64 in Britain report a long term illness or disability; this is the case for 74% of people aged 85+; key causes are musculoskeletal illness & cardiovascular disease • Physical ill health & disability are the most consistent risk factors relating to depression among older people • Rates of depression are approx double compared with healthy counterparts; estimated that 70% of new cases of depression in older people are related to poor physical health • Highlights the fact that it is not age per se which creates vulnerability but the impact of disability &/or chronic illness which are simply more common amongst older people • Further, that it is specifically their role in increasing immobility, reducing opportunities to go out & undermining independence that create mental health problems • Higher levels of education appear to be ‘protective’ (Victor, 2005)

PROTECTIVE/VULNERABILITY FACTORS: SOCIAL RELATIONSHIPS & SOCIAL SUPPORT • There is considerable evidence to suggest that engagement in family, social & community life promotes mental health • Involvement in meaningful activities & having relationships with other people, meets a range of social & emotional needs: for intimacy, companionship & enjoyment (Godfrey & Denby, 2004) • Higher levels of social support are known to act as a buffer against depression • Where age related losses, such as those related to a disability, impact on social engagement & social relationships, mental health may be threatened. • Having a role in the local neighbourhood, volunteering, or taking a class are all identified as protective of mental well being • Community facilities, civic and social opportunities & accessible leisure & educational resources all protect against isolation & exclusion & enhance opportunities for participation

PROMOTING MENTAL HEALTH IN LATER LIFE - SECURING WELL BEING • The framework: makes visible the dimensions of later life that contribute to mental well being & provides a lens through which to identify & explore them • It also acknowledges the role of the life course & the interlocking & overlapping nature of many of the issues • … And foregrounds the fact that the determinants of mental health are located at a number of different ‘levels’ within the individual & their family; the community; & wider society • These can helpfully be conceptualised as concentric circles extending from the individual outwards • It axiomatic that interventions to promote mental health need to be directed at each ‘level’

hhhhhh Society/National hhhhh Community & Neighbourhood Mental Health promotion: circles of influence Individual & Family

Promoting mental health in Later life – Addressing threats to Quality of life

Dynamic of gains and losses • Socioeconomic situation • Material • circumstances • Social & physical • environment • Personal resources • Individual • Social network: family & • friends • Community • Meaning of the experience • Cultural and normative • expectations • Constraints and • opportunities Socio-cultural Model: Mental Health & Successful Ageing Stimulates adaptive behaviour (selection compensation optimisation) Successful ageing

Socio-cultural model of successful ageing • SCIE E-LEARNING OBJECTS ‘Introduction to mental health of older people’ • See Model link = http://www.scie.org.uk/publications/elearning/mentalhealth/index.asp

A note on Dementia ….. • The framework has considerably more explanatory power in relationship to functional mental ill health than for organic disorders • BUT … dementia, especially vascular dementia, does have some roots in disadvantage: poverty, diet, level of education • Even with Alzheimer’s disease there is recent evidence that environmental factors do play a role: smoking, & high blood pressure & high cholesterol levels in mid life increase the risk (Alzheimer's Society, 2007) • Also vascular disease predisposes people to AD as well as to vascular dementia • Although more work is needed, suffice to say that dementia does not entirely overwrite life course & socio-cultural influences

Conclusion • Mental health is both a part of, and intrinsically bound up with, overall well being; identified by older people as a pivotal dimension of quality of life • Mental health outcomes are a product both of life course issues & current access to resources • Threats to mental health exist in a number of domains; as do protective factors - role of mental health promotion is to bolster protection & address risks • Effective promotion of older people’s mental health requires action across a range of different areas at a number of levels • Poor mental health is not inevitable in old age; much can be done to reduce the incidence & impact of mental ill health & promote mental health

references • Age Concern (2007) Improving services and support for older people with mental health problems, London, Age Concern • Age Concern & Mental Health Foundation (2006) Promoting Mental Health & Well Being in Later Life, London, Age Concern • Alzheimer’s Society (2007) Dementia UK, Alzheimer’s Society, London • Bowling, A (2005) Ageing Well: Quality of Life in Old Age, Open University Press, Berkshire • Godfrey, M & Denby, T (2004) Depression and Older People, Policy Press, Bristol • Livingstone, G., et al, (2008) Successful ageing in adversity - the LASER longitudinal study, Journal of Neurology, Neurosurgery & Psychiatry, 79: 641-645 • Milne, A (2009) Mental Health & Well Being, in T. Williamson (Ed) Older People’s Mental Health Reader. Mental Health Foundation & Pavilion Publishing, Brighton • Milne, A and Williams, J (2000) Meeting the Mental Health Needs of Older Women: Taking Social Inequality into Account, Ageing and Society, Vol. 20, No. 6 pp 699-723 • Office for National Statistics (2004) Focus on Older People, ONS: London • Social Care Institute for Excellence e-learning ‘An introduction to mental health of older people’ - http://www.scie.org.uk/publications/elearning/mentalhealth/index.asp • Victor, C (2005) The Social Context of Ageing, A Textbook of Gerontology, Routledge, Abingdon • Victor, C., et al (2009) The Social World of Older People: Understanding Loneliness and Social Isolation in Later Life, McGraw Hill

Alisoun Milne, Senior Lecturer in Social Gerontology, University of Kent a.j.milne@kent.ac.uk