Geriatric Psychiatry: Perceptions, Presentations, and Treatments
11.3 Mental Health in Minority and Ethnic Groups
them (i.e., lower socioeconomic status, lower education, racism, discrimination, etc.). One reason for this is their strong reliance upon religious faith that also serves as a protective factor against suicide [ 30 ]. Unfortunately, this can also affect views toward psychiatric treatment. Religious individuals may refrain from seeking treat- ment options that appear to be disparaging of their religious beliefs [ 31 ].
Individuals who were not previously religious or spiritual prior to diagnosis may turn to religion to cope. Physical and mental illness can force individuals to face mortality. During this time, religion may be used more frequently to cope in order to interpret and explain hardships [ 31 ]. Religion has positive and negative effects on mental health and treatment. Practitioners should examine how these effects may interact to provide the best form of care for patients [ 32 ].
11.3.1 Depression
Depression is one of the most prevalent mental conditions and has a higher prevalence rate among minority and ethnic groups when compared to Whites.
Conversely, among those meeting 12-month major depression criteria, some minority and ethnic groups are the least likely to receive the appropriate treatment [ 41 ].
The criteria for Major Depressive Disorder (MDD) according to Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (D SM-5 ) [ 117 ] include either a depressed mood or loss of interest along with four or more of the following symptoms : (1) signifi cant weight loss or gain, or decrease or increase in appetite; (2) insomnia or hypersomnia; (3) psychomotor agitation or retardation; (4) fatigue or loss of energy; (5) excessive guilt or feelings of worthlessness; (6) poor concentration; or (7) recurrent thoughts of death, sui- cidal ideation, or suicide attempt. Symptoms have to be present for 2 weeks and cause signifi cant stress or impairment in daily functioning. They also cannot be attributed to another medical condition or the effects of a substance. These cri- teria may not apply to older adults since often there are different symptoms noted in late life depression .
Late life depression ( LLD ) can result in greater disability, morbidity, and mortality, especially when left untreated. Depression produces the greatest decrement in health compared with other chronic diseases, such as angina, arthritis, asthma, and diabetes [ 42 ]. LLD carries additional risk of suicide and family caregiving burden [ 43 , 44 ]. Diagnosis can be diffi cult, as there are often comorbid medical conditions that often have similar symptoms. Instead of a depressed mood, older patients may experience irritability, anxiety, or change in cognition. They may also become more withdrawn and exhibit mild to moderate paranoia [ 45 , 46 ].
African Americans and depression . Older African Americans have a higher rate of signifi cant depressive symptoms when they have a comorbid physical condition. They also may focus more on somatic complaints or report symptoms of anger, irritability, or denial of illness [ 47 ]. In another study, investigators found that older African Americans in urban areas were more at risk for clinical isolation, which is a lack of social support network from family, friends, or neighbors [ 48 ]. In the sample, rural area residents tended to have stronger and more extensive social support networks with family, friends, and neighbors.
While the urban residents’ social support system was primarily provided by unrelated individuals, health care service providers and, occasionally church and family members [ 48 ]. In another study, Gitlin et al. [ 49 ] found older African Americans can have positive attitudes and beliefs as well as be willing to engage in treatment options if diagnosed with depression.
Hispanics and depression . Hispanics are twice as likely to seek help for mental health problems from primary care providers as from mental health specialists
[ 50 ]. Hispanics usually complain of weakness, multiple aches and pains, dizzi- ness, palpations, and sleep disturbances, which are related to depression [ 51 ].
Higher levels of depression have been associated with cognitive decline in older Hispanics [ 52 ].
Lewis-Fernandez et al. [ 51 ] offer the following recommendations to assess Hispanic patients suffering from depression and unexplained medical symptoms:
• Inquire about the patient’s understanding of the somatic symptoms.
– Are they visible signs of acknowledged emotional distress.
– The cause of secondary emotional problems.
– A way of asking for help .
• Clarify the patients’ use of specifi c cultural idioms of distress.
– Nervios (nerves).
– Anger-related illness such as biles (bile) or colera (rage).
• Some patients may emphasize somatic symptoms to “speak the medical lan- guage” in attempts to get the practitioner to focus on a medical cause instead of the true emotional issues.
• Recognize that somatic symptoms are real and not imagined.
• Explore physical symptoms in the context of stressors with open-ended ques- tions such as: “What are the problems that you are facing now that creates diffi - culty or distress?”
• Rule out alternative physical disorder, but if depression or other psychiatric dis- orders are evident and physical symptoms are clearly medically unexplained, avoid unnecessary referrals or lengthy workups.
• Discuss with the patient your understanding of their physical distress in relation- ship to their life situation and stressors.
– Patients may fi nd biopsychosocial interpretation helpful.
• Recognize that some patients with somatization are unable to fi lter out their per- ception of irrelevant bodily stimuli and their awareness of bodily sensations may get reported as physical distress.
– Somatosensory amplifi cation .
• Consider that a minority of patients may also suffer from alexithymia.
– Alexithymia is an extreme inability to verbalize feelings or emotional states.
• Patients with somatization feel relief when they perceive that physicians believe and listen to them.
Even though these recommendations are used to assess Hispanic patients, they seem appropriate to use for any patient who may have vague and unexplained somatic complaints.
11.3.2 Anxiety
The prevalence of anxiety in the elderly community ranges from 1.2 to 15 %, and in the clinical settings from 1 to 28 %. However, prevalence of anxiety symptoms is much higher, ranging for 15–52.3 % in the community samples and 15–56 % in clinical samples [ 53 ]. In my clinical experience, patients have often tried to relate the anxiety symptoms to a physical problem, which often leads the primary practi- tioner to also seek a medical cause such as complaining of chronic stomach pain as a symptom of anxiety. Some of the risk factors associated with both prevalence and incident of anxiety in the elderly include personality traits; inadequate coping strat- egies; previous psychopathology; and qualitative aspects of social network, stress- ful life events, and female gender.
Diagnosis of generalized anxiety disorder, according to DSM- V , includes excessive anxiety and worry occurring for at least 6 months in which the indi- vidual fi nds it diffi cult to control the worry. It is also associated with three or more of the following symptoms: (1) restlessness or feeling keyed up or on edge, (2) being easily fatigued, (3) diffi culty concentrating or mind going blank, (4) irritability, (5) muscle tension, or (6) sleep disturbance. The symptoms cause clinically signifi cant distress or impairment in daily functioning. The distur- bance is not caused by a substance, medical condition nor explained by another mental disorder.
When assessing someone for anxiety disorder remember that is not the same as everyday stress and worrying, but becomes problematic when it interferes with ones’ day-to-day functioning. Elderly individuals with generalized anxiety disorder have impaired short-term memory and often cooccur with depression [ 54 , 55 ].
High rate of unemployment, lower socioeconomic status, racism, and exposure to crime are signifi cant stressors that affect African Americans, Hispanic, and other minority groups [ 56 ]. However, these groups have lower rates of generalized anxi- ety but have high rates of developing PTSD [ 57 , 58 ].
11.3.3 Bipolar Disorder
Elderly patients with bipolar disorder more frequently present with melancholic depression, (symptoms include psychomotor retardation, anhedonia, and cogni- tive slowing) as well as suffering with more medical comorbidities when com- pared to younger patients with bipolar disorder. Also a predominantly depressed polarity characterizes the course of the illness [ 59 ]. In general, African Americans are often under diagnosed for bipolar disorder and overdiagnosed with schizo- phrenia [ 60 , 61 ]. African American and Latinos with bipolar disorder often exhibit higher rates of increased self-esteem or grandiosity during mania at much higher rates than Whites [ 62 ].
11.3.4 Psychosis
Psychosis is when someone’s reality testing is grossly impaired. For most individu- als, it presents as delusions, hallucinations, disorganized thought process, or disor- ganized/odd behaviors. Late-life psychosis is more prevalent than once thought with 10 % of geriatric patients admitted in the acute inpatient psychogeriatric unit presenting with symptoms [ 63 ]. Rates of up to 10 % have been found in older adults living in the community [ 64 , 65 ]. Almost 25 % of nursing home residents are pre- scribed antipsychotics, with the vast minority not carrying a diagnosis for which the medications are indicated [ 66 ]. Psychoses can either be primary (caused by a psy- chiatric disorder) or secondary (due to a medical disorder). Primary psychoses should be viewed as diagnoses of exclusion after a thorough evaluation of second- ary causes has been ruled out .
African Americans and psychosis . African Americans are often overdiagnosed with schizophrenia when they present with psychotic symptoms [ 60 , 67 , 68 ]. They are more likely, than their White counterparts, to be diagnosed with schizophrenia and less likely with psychotic depression or other affective disorders [ 69 , 70 ].
However, there are several other conditions that could present with psychosis in the elderly such as delirium, dementia, and depression.
Asian Americans and psychosis . In Asian Americans, there are unique cultural and noncultural issues impacting diagnosis and treatment of psychosis, such as tra- ditions and rituals, spirituality, language, stigma, and help-seeking behaviors includ- ing use of alternative medicine [ 71 ]. Acute psychotic disorders with good prognosis, such as Brief Psychotic disorder and Psychosis-like experiences may be more prevalent in Asians and may sometimes be misdiagnosed as schizophrenia or schizoaffective disorder [ 71 ].
Latinos and psychosis . DeVylder et al. [ 72 ] reported acculturative stress to be associated with visual and auditory hallucinations among Asians but only with hearing voices among Latinos. There was also an increased risk for psychotic-like experiences (PLE) among Latinos that was primarily associated with younger age of immigration. Age of immigration has a signifi cant relationship with psychotic- like experiences. Those immigrating to the United States before the age of 12 had an increased risk of PLE. This could be due to other environmental factors such as low socioeconomic status, perceived discrimination, and childhood separation from parents [ 72 ].
11.3.5 Behavioral and Psychological Symptoms of Dementia
The behavioral and psychological symptoms of dementia (BPSD) include agitation, aggressiveness, apathy, wandering, paranoia, anxiety, depression, and hallucina- tions. With regards to depressive symptoms in dementia, more recent studies have shown that Latinos endorsed more symptoms than African Americans and
non- Hispanic Whites [ 73 ]. However, in previous studies in patients with dementia, there was a lower prevalence of depressive mood in Hispanics than African Americans patients when compared to White patients [ 74 ]. One reason for the dif- ferent outcomes has been explained by the insensitivity of the depression screening tools and reporting bias [ 75 ]. Ethnic-specifi c instruments can more accurately mea- sure prevalence. For example, the Behavioral Problem Checklist-Spanish (BPC-S) is a brief psychometrically sound caregiver report instrument that assesses symp- toms of mood disturbance and behavioral disruption in Hispanic patients with dementia [ 76 ].
11.3.6 Suicide
Older adults may be at higher risks for suicidal behaviors, due to chronic physical illness, mood disorders, feelings of hopelessness, alcohol abuse, anxiety, bereave- ment, and social isolations [ 77 ]. Classically, society attributes suicidal ideation and completion with younger individuals; however, those over 75 years of age have an increased risk of suicidal behavior. Of elderly individuals who commit suicide, 90 % was found to suffer from a psychiatric disorder [ 78 ]. Ethnicity infl uences suicidal behavior due to difference in psychoses and whether one is an immigrant or US-born citizen. Suicidality is less common among the large immigrant segments of the Hispanic and Asian-American populations. Also, suicide attempts among ethnic groups were accounted by differences in psychiatric disorders among these groups.
Therefore, practitioners should consider ethnicity and factors related to citizenship, when assessing suicidality [ 79 ].
African Americans and suicide . The estimated lifetime prevalence of suicidal ideation and attempts among older African Americans in the US is 6.1 and 2.1 % [ 80 ]. In older African Americans with both active and passive suicidal thoughts, addition risk factors include social dysfunction, lack of a confi dant, low religiosity, and low or lack of social support when compared to their White counterparts [ 81 , 82 ]. Subjective social support is a potentially modifi able risk factor for suicide that could be amendable by using home health care workers [ 83 ].
Asian Americans and suicide . According to Dong et al. [ 84 ], the prevalence rate for older US Chinese adults is 9.4 %, which as is noted as higher than that of older Chinese adults living in Hong Kong (5.5 %) and Beijing (2.2 %) [ 85 , 86 ].
Dong et al. [ 84 ] offered the hypothesis that US Chinese older adults, in which the majority of the population was fi rst-generation immigrants, may experience sig- nifi cant acculturation stress that predispose them to higher lifetime prevalence for suicidal ideation than those who live in their home countries. Risk factors included older age, being female, lower health status, worsening health, lower income, and living with fewer people.
Latinos and suicide . Hispanics reported suicidal ideations and suicide attempts less than non-Hispanic Whites, with lifetime among Latinos being 10.1 % and 4.4 %, respectively [ 87 , 88 ]. In addition, female gender, high acculturation (born
in the United States and English speaking), and high levels of family confl ict were independently and positively correlated with suicide attempts among Latinos, even among those without any psychiatric disorder [ 87 ]. Perez-Rodriguez and colleagues [ 89 ] found a positive association between higher level of acculturation and increased risk for suicidal ideation and attempts. One theory for this is high levels of acculturative stress which involves psychological distress associated with leaving the culture to which one is accustomed and integrating into a new environment which can lead to further isolation and discrimination [ 90 ]. This association was manifest across multiple dimensions of acculturation, including age at migration, time spent in the United States, language orientation, predomi- nance of Hispanic social network, and degree of Hispanic/Latino ethnic identifi - cation. Their results highlighted protective aspects of the traditional Hispanic culture, such as high social support, coping strategies, and moral objections to suicide, which are modifi able factors and potential targets for public health interventions aimed at decreasing suicide risk [ 89 ].
11.3.7 Primary Care-Based Intervention
Bruce et al. [ 43 ] investigated the use of a primary care-based intervention on reduc- ing major risk factors for suicide in late life. This intervention consisted of (1) addressing physician knowledge for treating geriatric depression in a primary care setting and (2) treatment management operationalized by depression care managers.
They use a heterogeneous population which included African Americans, Hispanic, and White patient groups. Their outcomes showed that suicidal ideation resolved more quickly in patients who received the intervention. Additionally, those same patients had a more favorable course of depression.