Getting mental health care makes the body healthier — especially for the elderly
Taking care of our minds is an often neglected aspect of aging. What are we going to do about it?
- Studies have shown that depression can worsen in our old age.
- Other mental health concerns, too, are not only debilitating on their own but they can often make it more difficult to treat other health conditions.
- However, recent advances in how we treat mental health in the elderly are making a big difference. Here's how.
It's an unfortunate fact of life that as we grow older, our bodies stop working as well as they once did. Our muscles weaken, tying our shoes can send our backs into spasms, our hearing and vision isn't as sharp as it used to be. It's a time when taking care of yourself is more important than ever.
But we often forget that our minds, too, need to be taken care of. According to the CDC, 20% of people over 55 have some kind of mental health concern. Yet only two-thirds of this group receive treatment for their condition. Out of any other group, older men have the highest suicide rate. One study found that older patients were more likely to be diagnosed with a major depressive disorder, and that their depression grew worse with age. Older participants were more likely to have chronic depression, took longer to be in remission, and experienced depression with greater severity, according to the same study.
While mental health is enough of a concern on its own, it can also make treating physical health issues more difficult. "There is no clear-cut demarcation where behavioral health comorbidities start and where physical comorbidities end," said Dr. Joseph Conigliaro, Northwell Health's chief of general internal medicine. "When a patient with diabetes or congestive heart failure or any number of issues also has depression, anxiety, or schizophrenia, providing consistent care becomes much more challenging."
Percentage of older adults who claim they don't receive the social and emotional support they need by state, which can put individuals at risk for developing mental health conditions.
Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.
Bringing psychiatry to primary care
How can we better meet the mental health needs of elderly patients? In his book, Healthcare Reboot, Michael J. Dowling points to the divide between psychiatry and primary care as a major issue. "While it was true that psychiatrics went to medical school," he writes, "their subsequent clinical training was so far removed from other doctors that they tended to live in a psychiatric silo. In many ways, psychiatrists had walled themselves off from the rest of the medical profession."
A Gallup poll on the perceived honesty of various professions shows another way in which psychiatry has been pushed aside. 85%, 75%, and 70% of respondents reported that nurses, pharmacists, and medical doctors had very high ethical standards, respectively. Only 41% of respondents reported that psychiatrists had very high ethical standards.
One way to bring psychiatry back into the domain of primary care is to do just that; tighten the connections between psychiatrists and general practitioners through the collaborative care model. In this system, a behavioral health care manager and a psychiatrist are incorporated into the primary care setting. The psychiatrist serves as a consultant for the primary care physician and the behavioral health care manager, who could be a psychologist or a nurse trained in managing mental health. The primary care provider has some training in screening patients for mental health issues. Rather than refer them to a psychiatrist, they can instead point them to the behavioral health care manager. This helps normalize the relationship between mental health and primary care and can reduce the stigma associated with seeking help for mental health conditions.
A study on the use of this model for older adults suffering from depression showed resounding success — using the collaborative care model doubled the efficacy of depression treatment. Over twelve months, half of the patients reported an at least 50% reduction in their depression symptoms compared with a 19% reduction in the control group. What's more, the system saves money. For every $1 spent on implementing the collaborative care model, hospitals get $7 back over the course of four years. Today, Northwell Health and other health care organizations have incorporated psychologists and other mental health professionals in their primary care clinics to help deliver the mental health care that elderly patients need.
Virtual reality: Not just for gaming
Addressing mental health issues in the elderly doesn't just have to take place in hospitals and clinics, however. Advances in technology are blurring the lines of where treatment can happen. Rendever, for instance, is a new project by MIT graduates that uses VR to help provide the elderly with mental health treatment. VR has the potential to serve as a powerful therapeutic tool for older adults, especially those in assisted living. Often, older adults in assisted living can feel isolated and trapped in their conditions; VR offers an avenue out of those conditions. In an interview with AARP, a co-founder of Rendever related a story about an isolated former pilot flying a simulated aircraft: "All of a sudden he was sitting in a pilot seat again, and all these stories started bubbling out of him." VR technology like Rendever have been used to treat PTSD, chronic pain, phobias, depression, and drug addiction. There's even some preliminary evidence that VR could be used to keep cognitive function sharp in old age.
From the clinic to the home
One major challenge for the elderly is mobility. It's not always practical for them to travel to a clinic, psychiatrist, or psychologist. The use of "virtual visits" has become increasingly more common for health organizations. Companies like Apple and Samsung are increasingly leveraging their smartphone technologies to provide easier access to healthcare records and tackle chronic conditions. For its part, Northwell researchers have helped pioneer the use of remote intensive care units, or eICUs, to watch over multiple patients at once from a central location.
It may seem as though technology like this wouldn't be useful for psychiatric issues; in fact, the opposite is true. For the elderly, easy access to a psychiatrist may make them more likely to reach out. For patients in assisted-living facilities or unable to travel, "telepsychiatry" is sometimes the only way they can gain access to a psychiatrist.
When it comes to the health of the elderly, a broken hip or a pneumonia diagnosis can overshadow the importance of maintaining a healthy mind in one's older years. Taking care of one's physical health will always be important, especially in geriatric patients, but it doesn't make sense to focus solely on treating a physical health issue while ignoring ongoing mental health concerns. Fortunately, advances in our institutions, systems, and technology are bringing mental health issues back into the spotlight.
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They came from different places and with different ideas, which still resonate today
- Early British settlement of the American colonies came in four distinct waves, from different places.
- Puritans, Cavaliers, Quakers and Borderers had their own ideas of what America should be.
- Some of the cultural fault lines in today's America can be traced back to those differences.
Four 'folkways'<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0MDY2NC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzOTAzNzk0OX0.YfBxVdS46dX1eUZhGA_4remlW4YYMIxlZ65wjQ2pyMs/img.jpg?width=980" id="d2108" class="rm-shortcode" data-rm-shortcode-id="2efd697c8c1a31a446da2d4f34168094" data-rm-shortcode-name="rebelmouse-image" alt="\u200bQuaker pioneer William Penn (center) treating with the Delaware Indians for the purchase of what was to become Pennsylvania." />
Quaker pioneer William Penn (center) treating with the Delaware Indians for the purchase of what was to become Pennsylvania.
Image: frieze by Constantino Brumidi (1865) in the Rotunda of the US Capitol; via Architect of the Capitol - public domain.<p>How many Americans are of British descent? It's a surprisingly difficult question to answer. Is that because, in an age of hyphenated identities, the founding one still is the default? Or has that identity become so amalgamated that it is now irrelevant? Perhaps the correct answer is: a bit of both. </p><p><span></span>In the 1980 Census, 61.3 million Americans (32%) self-reported British ancestry; most claimed English descent (26%), followed by Scottish (4%), and tiny amounts of Welsh (<1%) and Northern Irish. In the 2010 Census, that figure had dropped to 37.6 million (14%), with just 8% reporting English heritage, 3% Scottish and 2% Scotch-Irish. </p><p>The precipitous drop in self-reported British antecedents corresponds in part with the rise of those who identify as (unhyphenated) 'American', up from 12.4 million (5%) in the 1990 Census to 20.2 million in 2000 (7%) – the largest growth of any ethnic group in the 1990s.</p><p>However, back around the year 1700, about 80% of the population of what was to become the United States were of English (or Welsh) descent, with about 11% of African origin, and the rest being Dutch (4%), Scottish (3%) and other European. The imprint of the British on early American society was overwhelming, diverse and long-lasting: the regional and cultural differences between the settler groups created distinct regional and cultural identities in America.</p><p>That's the argument made by David Fischer, a history professor who in 1989 published a 900-page treatise on early migration to North America called <em><a href="https://global.oup.com/ushe/product/albions-seed-9780195069051" target="_blank">Albion's Seed</a></em>. He identified four British 'folkways' that came over to the other side of the Atlantic in the 17th and 18th centuries (<em>see map</em>), each with their own ideas about the liberty they wanted to find there.<br></p>
From exodus to flight<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0MDY2NS9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY0NDg1MzczOX0.-LwTLCpuIub9QhTVWL9vhnd8Jlz9j8aRyt9bePqQPuo/img.png?width=980" id="65f97" class="rm-shortcode" data-rm-shortcode-id="4457df0ca7f66fe87026322bad771da6" data-rm-shortcode-name="rebelmouse-image" alt="\u200bMap showing the origin and destination of four British 'folkways' that influenced American society." />
Map showing the origin and destination of four British 'folkways' that influenced American society.
Image: Geni.com<p><strong></strong><strong>1. The Exodus (1629-41)</strong></p><ul> <li>About 21,000 Puritans, migrating from East Anglia to New England.</li><li>These religious fundamentalists believed in 'ordered liberty': everybody had the right to live by their own rules, and the duty to live according to God's law.</li><li>The Puritans were a major influence on the culture of the Northeastern US, especially in terms of business and education.</li></ul><p>These religious fundamentalists are the ones who came over on the Mayflower and gave America Thanksgiving and the self-image of being a 'City on a Hill'. Puritan society was gloomy and repressive: 'exceeding the bounds of moderation' was a punishable offense, and even just 'wasting time' got you into trouble.</p>The other side of the coin: life was very well-ordered. There was little income inequality and crime rates were low. Not only was charity towards poor the rule, being uncharitable was, yes, a punishable offense. Domestic abuse was punished severely. Women had a relatively high degree of equality. And government operated via town assemblies in which all could have a say.<br><br><strong>2. Cavaliers and their Servants (1642-75)</strong><ul><li>Some 45,000 Cavaliers drawn from English nobility and their indentured servants, migrating from the South of England to Virginia and the Lowland South.</li><li>These aristocrats believed in 'hegemonic liberty': dominion over self, and others. In other words: keeping slaves was okay, but domination by others was not.</li><li>The Cavaliers were the foundation of plantation culture in the South. </li></ul><p>The Cavaliers came from the losing side of the Civil War in England, which was now led by the Puritan-inspired Oliver Cromwell. Royalist, Anglican and aristocratic, they brought along with them their indentured servants – more than 75% of the total migration – hoping to recreate in Virginia and environs the socially stratified agrarian society they had left behind.</p><p><span></span>When their servants began dying en masse, they started importing African slaves, laying the groundwork for the race-based slavery system that underpinned the economy of the South until the end of the Civil War.</p><strong>3. The Friends' Migration (1675-1725)</strong><ul><li><strong></strong>Around 23,000 Quakers, migrating from Northern England to the Delaware Valley in Pennsylvania, and later to the Midwest.</li><li>These religious liberals believed in 'reciprocal liberty': granting others the freedoms they wanted for themselves, including the right to vote, to own, to be free, to worship and to a fair trial.</li><li>Quakers had an important impact on the industrial culture of the Mid-Atlantic and Midwestern regions of the US.</li></ul><span></span>Halfway between the fun-hating Puritans and the pleb-hating Cavaliers, the Quakers seem modern and likeable. Believing everybody intrinsically good, they practiced tolerance, pacifism, gender equality and racial harmony. They opposed slavery, the death penalty, and cruelty to animals and children.<p>Quakers replaced a wide range of social acknowledgements according to rank (bows, nods, grovels) by a single, neutral equivalent: the handshake. Quakerism was perhaps one of the first Christian denominations to become indistinguishable from liberal, secular modernity. On the other hand, they were more prudish even than the Puritans. Doctors had a hard time treating Quakers because they described everything from their necks to their waists as their 'stomachs', and everything below as their 'ankles'. </p><p><strong>4. The Flight from Northern Britain (1717-75)</strong></p><ul><li>Some 250,000 'Borderers', migrating from the Anglo-Scottish borderlands and Ulster to the Backcountry of Appalachia.</li><li>These individualists believed in 'natural liberty': freedom to do as one pleases, without interference from society or government.</li><li>Borderers contributed to the rural culture of America's South and the ranch culture of its West. </li></ul><p><span></span>Inhabiting the border regions between Scotland and England, and between protestant settlers and catholic natives in Ireland, the Borderers were used to violence and lawlessness, and to lives that were nasty, brutish and short. </p>It is no coincidence that they ended up in Appalachia, at that time itself a violent border region. It was the kind of world they knew. Borderers were wary of government, prone to violent family feuds and not bothered by traditional morality. By one estimate, in the year 1767, 94% of all 'backcountry' brides were pregnant on their wedding day.<p><span></span>These Borderers were not much beloved by other settler groups in America. One Pennsylvanian writer called them "the scum of two nations". But the Borderers also contributed vigorously to the success of both the American Revolution and America's westward expansion. </p>
'Blue' vs. 'Red'?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0MDczNy9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1MzE5MTc4NH0.EtbfEc9BlGG8R4VlyHr2W7kQ0LzvRdAHRRRlsEI01Pg/img.jpg?width=980" id="ce2a3" class="rm-shortcode" data-rm-shortcode-id="ba2cd744238f9a08ce63e85be2860528" data-rm-shortcode-name="rebelmouse-image" alt="Representative Preston Brooks (SC) caning Senator Charles Sumner (MA) on the Senate floor. The attack, on 22 May 1856, symbolised the breakdown of civil discourse between North and South, prefiguring the Civil War." />
Representative Preston Brooks (SC) caning Senator Charles Sumner (MA) on the Senate floor. The attack, on 22 May 1856, symbolised the breakdown of civil discourse between North and South, prefiguring the Civil War.
Image: lithograph by John L. Magee (1856); public domain.<p>It's tempting, and perhaps not entirely unjustified, to see in these four strains of British 'folkways' the antecedents of some of America's current cultural divides. One might for example see Puritans and Quakers as constituting elements of the 'blue' tribe, while Borderers and Cavaliers could be considered the ancestors of the 'red' tribe.</p><p><span></span>But thinking of America as a "death match between Puritan-Quaker culture and Cavalier-Borderer culture", as one commentator put it, is perhaps a bit too easy. There may be plenty of overlap within either pair, there is also much to distinguish each from the other. And then there are other and subsequent migrations contributing to and complicating the picture.</p><p>Nevertheless, a bit of cultural archeology can be illuminating, if only to see where the bodies are buried.<br></p><p><strong><br></strong></p><p><strong>Strange Maps #1049</strong></p><p><em>Got a strange map? Let me know at </em><a href="mailto:email@example.com">firstname.lastname@example.org</a><em>.</em></p>
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