Particular dynamics of social position, inequalities and mental health coalesce at the individual level, as we approach retirement and become older adults. Older adults who are healthy, have an adequate source of income, educated beyond a basic level, active and retain extended social net- works tend to adjust well to the challenge of retirement. Compared to people who retire voluntarily, those who are forced into retirement tend to be more depressed and unhealthy. A common cultural assumption has been that early retirement is inherently beneficial because it affords opportunities for more leisure and relief from the stress of job conditions and dissatisfaction. However, recent evidence suggests instead that it is associated with cognitive decline. This may be attributed in part to the shrinking of social networks (particularly at work) that keep people mentally agile (Borsch-Supan and Schuth 2013). This recognition of the importance of environmental and social networks is now translating into policies that also recognize their importance. In particular it has had an impact on new ways of thinking about primary and social care, which focus on the environ- mental and social settings of ageing. In relation to the increasingly recognized importance of the degree or lack of social connectivity, via social networks, two sociologically imbued terms have tended to be used interchangeably: ‘loneliness’ and ‘social isolation’.
In research on older people, ‘loneliness’ generally refers to a negative evaluation of ‘the nature, quality and quantity of an individual’s overall level of social interaction and engagement’
(Victor et al. 2006), whereas social isolation has been defined as the ‘separation from social or familial contact, community involvement, or access to services’ (AGE UK 2010). ‘Solitude’, a posi- tive construct linked to mental states such as meditation and a precondition of a self-help tradition based on ‘mindfulness’, has been defined as something positive and productive, ‘a constructive way of being separated from others in order to be by and with oneself’ (Ettema et al. 2010: 142). Thus discussions of the psycho-social aspects of ageing and its relationship to being alone and being with others have to be considered in relationship to the nuances of these subjective and objective nuances of life (at any age), but have become particularly relevant to research on ageing.
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Service provision for older people is skewed towards providing for dementia (discussed below). However, there has been some effort to provide for older people experiencing depression from within primary care. Treatment regimens for depression seem to mirror those being pro- vided for other groups, which focus mainly on the use of antidepressants (Baldwin and Thompson 2003). More normalized activities might seem to offer better amelioration. For example, gardens have been identified as a ‘therapeutic landscape’: gardening activities have been found to offer comfort and the opportunity for emotional and spiritual renewal, and communal gardening activ- ity on allotments has been found to contribute to psychological well-being, through the provi- sion of a mutually supportive environment. This may enhance emotional well-being by combating social isolation (Milligan et al. 2004). However, social norms about depression and its management among health professionals are likely to have an impact on access to the means of prevention and management. Therapeutic nihilism (the feeling that nothing can be done for this group of patients) is a feature of primary care professionals’ views, while older patients also seem to be characterized by passivity and limited expectations of treatment.
The Third Age, and focus on dementia and depression in older people
The emergence of the notion of the ‘Third Age’ is defined and explained by Chatzitheochari and Arber (2012: 455) thus:
the decrease in the retirement age and the increase of healthy years people were expected to enjoy after retirement laid the foundations for a different experience of mature age after the relinquishment of paid work and family roles. Combined with the increased opportunities for leisure participation and the more ‘refined’ needs and interests of newer generations as a result of different socialization experiences and resources, these changes would lead to an altered trajectory of individual ageing; the Third Age was thus conceptualized as a new life- course stage of extended and self-fulfilling leisure and community participation following retirement. Its emergence was understood as a uniquely modern phenomenon that constituted a key development in the transformation of later life and of the entire life-course structure in Western societies.
This discourse on the emergence of the Third Age as a period of relative fulfilment and ongoing engagement with active leisure seems on the face of things to coalesce with the evidence discussed above of the relatively better mental health that is experienced as we age (e.g. Blaxter 1990).
However, the latter does not apply to all. Active ageing seems to coalesce with the ‘habitus’ and the cultural expression of those who are also culturally and materially already advantaged. Moreover, this perspective seems to bracket out the significance given to accounting for deterioration in social competence, and specific mental health conditions which is the more usual focus of mental health as we age. To illustrate the point:
• 60,000 deaths a year are directly attributable to dementia. Delaying the onset of dementia by 5 years would reduce deaths directly attributable to dementia by 30,000 a year.
• Family carers of people with dementia save the UK over £6 billion a year.
• 64 per cent of people living in care homes have a form of dementia.
• Two-thirds of people with dementia live in the community while one-third live in a care home.
The most recent estimates suggest that in 2013 there are around 670,000 people with dementia in the UK. Although rates of dementia are broadly set to rise (because of changes in longevity), there is evidence of a cohort effect. It seems that ‘later born populations’ have a lower risk of developing dementia than those born earlier in the twentieth century (Matthews et al. 2013). The latter effect seems to be a function of cohort differences in norms of diet and exercise.
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Health economic analyses suggest that the financial cost of dementia to the UK is over £17 billion a year (Comas-Herrera et al. 2007). However, the salience of dementia in mental health services and its purported biological causes in older people may be exaggerated. As well as people with dementia needing social support to maximize their quality of life and avoid physical jeopardy, there are many more older people with cognitive problems who have no proven neurological con- dition. Kitwood (1988) points out that Alzheimer’s dementia can only be properly diagnosed post- mortem. Moreover, some people who are clearly confused and suffering impaired memory show no post-mortem neurological signs. The loss of personhood, which accompanies the progression of dementia, has also been linked to the notion of ‘social death’; those who are close to the sufferer come to believe and sometimes act as if the person is already dead (Sweeting and Gilhooly 1997).
Another point to note about dementia is that while it is mainly a problem of old age, it can occur, albeit more rarely, in middle age (‘pre-senile dementia’). An example, of an even younger population being affected is the small but increasing prevalence of Creutzfeldt-Jakob Disease (CJD) among younger adults, which appears to be causally related to eating products of cattle infected with Bovine Spongiform Encephalopathy (BSE) during the 1980s. Epidemiologists remain uncertain about the long-term impact of infection inherited from that time. (The WHO reports that 175 cases of CJD emerged in the UK and 49 cases emerged in other countries from October 1996 to March 2011: www.who.int/mediacentre/factsheets/fs180/en.)
There is a secondary mental health impact of dementia, which affects informal carers (Morris et al. 1988). Stress reactions are common in this group of carers, although some other studies high- light positive, as well as negative, psychological features of the caring role (Orbell et al. 1993). In Chapter 12 we examine the problematic status of the concept of ‘carer’. However, here we will note that, in those with advanced dementia, direct physical care is demanded in a way that is usually not implied in younger patients with diagnoses such as ‘schizophrenia’.
Dementia is also associated with contention between informal and formal health care workers about diagnosis and treatment. One study found that diagnosis may involve conflict between GPs, family members and the person with dementia. Compared to informal carers, GPs did not consider that diagnosing dementia early was particularly important and even thought it might be harmful, and so they were sceptical about the advantages of dementia medications (Hansen et al. 2008).
While dementia may have become a dominant image in modern culture of becoming elderly, depression is actually more prevalent among the older population. While the prevalence of demen- tia is about 5 per cent in the over 65s, rising to just below 20 per cent for those over 80, depression is much more common in the younger age band of older people. In Britain, community surveys indicate prevalence rates for depression of between 5 per cent in Edinburgh (Maule et al. 1984) and 26 per cent in Newcastle (Kay et al. 1964) for people over 65. Other studies more typically quote rates of 11 per cent to 15 per cent (Copeland et al. 1987).
About 2 per cent of the UK population of over-65s is in residential care. In this particular popu- lation, the prevalence of depression rises dramatically. A London survey of 12 old people’s homes revealed that around 40 per cent of the residents were depressed (Mann et al. 1984). Surveys in Sydney, Australia (Snowden and Donnelly 1986) found one-third of the residents depressed, and a similar survey finding was reported from Milan, Italy (Spagnoli et al. 1986). Mild depression is more common in older women than men and it is also more prevalent in those suffering from physi- cal illnesses (Brayne and Ames 1988).
The extent of the association of depression and physical ill-health was shown by a study of 100 patients referred with depression to a psychogeriatric service over a 30-month period (Dover and McWilliam 1992). The authors found that only 3 per cent of the men and 20 per cent of the women patients were physically well. The rest had a variety of serious complaints including can- cer, cardiovascular disease, arthritis, deafness and respiratory problems. Sixty-five per cent of the sample had ‘multiple illnesses’. Moreover, many of the drug treatments for some of these physical
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disorders are known to cause or amplify depressed mood, suggesting an iatrogenic component in this group of depressed physically ill patients. The association of depression with physical illness in old age is highlighted by a recent review of several studies of medical (i.e. not psychiatric) inpa- tients which concludes that only one in five recover from their lowered mood state before death (Cole and Bellavance 1997). Suicide rates also increase in the older age group, and this is mainly accounted for by the high rates of male deaths.
What are the social implications of the data from psychiatric epidemiology of depression in older people? Starting with the very high rates of depression in residential homes, there are three explanations for these prevalence rates, which are not mutually exclusive:
1 It could be that those selected to enter these homes have been adjudged by relatives or professionals already to be in poor mental health, or vulnerable because of their lonely and under-supported home conditions (hence their referral to the homes).
2 The under-stimulating environment of these homes may induce apathy and morbid intro- spection (in the jargon of psychiatry, ‘dysphoria’). This has led some psychiatrists of old age to speculate that the homes may contain a number of people who are not ‘clinically depressed’ but who, instead, suffer from environmentally induced dysphoria, which may dissipate with a more stimulating care regime (Pitt 1988). Such a construction on the data of course assumes that there are clear demarcations to be made between clinical descrip- tions of ‘true’ depression and other experiences, such as apathy, anomie, listlessness, sad brooding and so on. Some other psychogeriatricians have pointed out that, in fact, it is not easy in the bulk of cases of sad old people to pigeonhole them as being ‘ill’ or ‘not ill’
(Murphy 1988).
3 Being moved to a residential facility is disruptive, entails a loss of previous surroundings and may mark a loss of personal control or autonomy. This imposed disruption and loss may have a depressing toll on the old person.
Turning to the community data on depression in older age, there are other explanations that could be offered for depression in old people who are not in residential care.
1 The probability of physical illness increases with age, and this in turn makes older people vulnerable to depression (Post 1969). However, Blaxter (1990), studying the self-reported physical and mental well-being of people across the life-span, found that overall psycho- social well-being improves relatively in old age. This could be partially accounted for by the lower expectations of life quality in old age leading to an under-reporting of distress.
Another factor is the dramatic improvement in the self-reported psychosocial well-being of richer people living in more comfortable surroundings (see below). An implication of the association of physical illness and depression is that good and effective physical care of depressed, poorer older people may have an ameliorative impact. Murphy (1988) sug- gests that the provision of aids for associated disability and other practical help to lessen the dependency of older physically ill people on their relatives may raise morale in the family system and thereby help lift depression.
2 Relationships that have accumulated during the life-span are lost. Spouses, friends and siblings die off around a surviving older person, making that person prone to the aggre- gating effect of grief. Depression in old age may be understandable in whole or part as cumulative grief.
3 Another social vulnerability factor is that of material adversity. In a community study of life events preceding depression in old age, Murphy (1982) found that poorer people who had experienced housing and financial difficulties were more prone to depression (of
84 A sociology oF menTAl heAlTh And illness
both mild and severe proportions) than better-off older people. Blaxter (1990) found that the psycho-social well-being of older people varied significantly with social class. Social classes 1 and 2 improved with age overall but those in social classes 4 and 5 deteriorated.
(For a discussion of class and other variables affecting social support see Wenger (1989).) 4 Another consideration is the role of supportive and confiding relationships. Lowenthal
(1965) found, like Brown and Harris (1978) in their study of younger women, that the presence of a stable confiding relationship was a protective factor against depression in old age. She also found that those most vulnerable are old people who try to form relationships and fail, rather than people who have coped throughout life alone. Murphy (1982) found in her community survey that 30 per cent of those reporting the lack of a confiding relationship were depressed. Given that 70 per cent of this group was not depressed, a multi-factorial model of vulnerability and protective factors seems to be indicated (as with Brown and Harris (1978)).
5 A final factor to consider is that of abuse in old age. Eastman (1994) suggested that esti- mates of abused older people in the USA vary from 600,000 to over a million. As with the abuse of children, prevalence and incidence are difficult to investigate accurately, given that abusers will typically deny the act. When the abuse occurs at the hands of paid car- ers, their job is at stake, as well as their reputation. Estimates of elder abuse rates in Scan- dinavia vary from 8 per cent to 17 per cent of older victims across Denmark, Sweden and Finland. In one of the Swedish samples 12 per cent of relatives admitted violence (Hydle 1993). Some authors extend the notion of elder abuse to medical neglect and iatrogenic disease in hospitalized older people (Gorbien et al. 1992). They include here: poor skin care, poor infection control, failure to make accurate physical diagnoses, leaving frail elders to risk falls and inadequate dietary provision (as a cost-cutting method). The imme- diate and long-term negative psychological effects of abuse are difficult to ascertain. It is self-evident that sexual or emotional abuse or physical violence against, or neglect of, old people will not enhance their mental health. A complicating factor is that confused older people who suffer from dementia are prone to violence themselves at times which may trigger reactive aggression in some of their care-givers. In one study (Paveza et al. 1992) it was found that in the year following a diagnosis of Alzheimer’s disease, 15.8 per cent of patients and 5.4 per cent of their carers were violent. Usually, age as a perpetrator risk factor for violence is linked to youth, but dementia raises the probability of violent acts in (one group) of older people.
Much of the work above takes a psychological or neuro-degenerative view about dementia. From a sociological perspective dementia as an ontological state can be viewed as a form of violence and destruction of the self. Davis (2004) points to the difficulty of the honesty this poses for pro- viding dignified care for people suffering from dementia, and the inevitable consequences of mourning for the social death of a lost person by those closely involved with them. Informed by Heidegger, from a philosophical standpoint Davis identified the experience of dementia as one of
‘what aspects of being change, or even disintegrate, as the existence of a person become subsumed by the dementia disease?’ (2004: 373). Seen in this way, from a phenomenological perspective, the state of dementia becomes one of the ‘fraying’ of the self. ‘Dementia effects the dismantling of the self until there is nothing left’ (Davis 2004: 374). This has practical implications for the dominant approach to diagnosis and management based principally on cognitions. In line with Kitwood and Bredin (1992), part of the project about caring for people with dementia becomes one of how social processes contribute to the functional decline of the affected person through a ‘malignant social psychology’. The ill-treatment and neglect of those with dementia is testimony to these processes, as evidenced by care scandals. A commitment to ‘unique personhood’ by Kitwood and Bredin,
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reversing the exclusion of the patient, based on defensive reactions held at an unconscious level and the socially debilitating obstacles created, is considered important now by those with this person-centred ethos to care. This is now shaping an ideal type of what dementia care should be.
Discussion
The sociological consideration of life-span and mental health is clearly uneven. At the start of life, socialization is considered to be important and there is certainly no shortage of interest in this arena of social determinism. Indeed, the consensus is very strong within social science that upbringing, acculturation and rule learning are all necessary considerations about societal functioning and the relationship between the individual and the collective. Admittedly, some have complained that this theorizing has been exaggerated (Wrong 1961) but, generally, primary socialization is given a privileged position in a variety of sociological (and psychological) theories. We noted at the start, though, that the sociological connection between primary socialization and mental health has been relatively under-scrutinized.
Psychoanalysis, a form of socialization theory itself derived from the psychological treat- ment of people with mental health problems, seems to have had a pervasive influence on different types of sociology. As far as childhood is concerned, sociological interest thus far has been theory- dominated. Despite this wide-ranging theoretical discourse about socialization, few sociologists have done empirical work on childhood and its problems (although there is the work of Finkelhor and Russell 1984) in the area of child sexual abuse and James and Prout (1990), who have studied
‘normal’ children).
The evidence of child sexual abuse we reviewed has, ironically, posed particular problems for clinical psychoanalysis. This theoretical framework, which has appealed so strongly to so many sociologists, has found itself accused of a central cultural role in suppressing evidence of the sex- ual abuse of children. This is because of Freud’s reversal of his theory in 1896. Prior to then, Freud tended to believe women patients’ recollections of incest from childhood. After that time, Freud succumbed to the more comforting notion that these represented subjective fantasies on the part of patients. This then became the accepted ‘wisdom’ when dealing with patient-reported abuse by Freud’s clinical followers (Masson 1985).
When we turn to the core of psychiatry, interventions in young adulthood and beyond sociol- ogy became enmeshed with a social movement in the 1960s to challenge or discredit clinical theory and practice. Scheff’s labelling theory (Scheff 1966) and Goffman’s critique of the asylum (Goffman 1961) from within symbolic interactionism were associated with ‘anti-psychiatry’. The retreat from this association with political activism and ‘counter-culture’ was then reflected in the sociology of mental health. The latter became more theoretical with the emergence of post-structuralist apprais- als of psychiatric discourse. This was, in part, a reaction against the humanism and civil libertarian- ism that had been associated with anti-psychiatry. These post-1960s sociological approaches can be contrasted again historically with the earlier epidemiological tradition of the social causationists.
The latter did not disappear from the map of the sociology of mental health, given the community survey approaches of, for instance, Brown and Harris and Murphy in the 1970s and 1980s.
The main sociological deductions about mental health problems in older people have, mostly, to be made from clinical researchers (social psychiatrists like Murphy). Consequently, harder data is considered from epidemiological surveys at the expense of sociological theorizing. While soci- ologists have theorized childhood extensively, but done little empirical work, they have done little in either realm as far as old people and their mental health problems are concerned. What theory does exist about later life has come from depth psychologists and has been poorly tested empiri- cally (e.g. Erik Erikson’s life-stage theory) or is from a position that emphatically privileges the individual over society (e.g. that of Carl Jung).