In June 2019 the NYC Department of Health and Mental Hygiene (DOHMH) issued a report on the health of older adults5. That’s good news since it reflects serious recognition of the aging of the population of New York City and of the need for the field of public health to pay greater attention to the health of older adults.
It’s also good news that the report notes that mental health is “essential to overall health and well-being.” Sadly, however, what the report includes on mental health is dreadfully inadequate.
Of 25 pages on health issues, only one is devoted to mental health. This despite the facts that 15-20% of older adults currently experience a mental disorder3,6, that roughly 50% of Americans have a diagnosable mental disorder in their lifetimes7, that mental illnesses are among the most disabling and expensive of all disorders, and that mental disorders exacerbate physical illnesses and contribute to premature death and disability10.
Remarkably, the report manages to squeeze discussion of 3 serious issues onto the single page on mental health—depression, suicide, and drug overdoses—making observations that point in important directions for public health.*
Unfortunately, by focusing on depression, the report gives a misimpression about the nature of mental illness among older adults. Of course, depression is a serious problem among older adults, but several epidemiological studies indicate that anxiety disorders are more common than mood disorders2,8,11.**
And, like depression, anxiety can have serious consequences contributing to social isolation, unwillingness to engage in activities, and rejection of needed help.
In addition, older adults—like younger adults—are subject to psychotic conditions, including schizophrenia, which, though not common, are the most disabling of mental disorders4.
Why the virtually exclusive emphasis on depression? One reason is that data about other disorders apparently are not available through the sources generally used by public health departments.
A more important reason, we suspect, is that in our ageist society old age is regarded as inherently depressing. Who wouldn’t be depressed about the slings and arrows of growing old? Depression must be widespread in old age.
But it’s not. The vast majority of older adults do not experience major depressive disorder, which—in fact—decreases with age among people living in the community2.
To be clear, we are not arguing that depression should be discounted as a major problem among older adults. It is a significant problem, and fewer than half of people who might benefit from treatment get it. In addition, only about 1/3 of people who get treatment get “minimally adequate” quality of care12. Much improvement is needed in the geriatric mental health system to address major depression and other mood disorders.
But improvement is needed to address other anxiety and psychotic disorders as well.
So, our first fundamental point is that the DOHMH report on healthy aging pays far too little attention to mental disorders other than depression.
Our second fundamental point is that mental health has both a negative and a positive side.
“Negative mental health” refers to mental disorders. When addressing negative mental health, the goals are to effectively treat or prevent mental illnesses.
“Positive mental health” refers to the achievement of well-being. This is possible at all ages—including old age. Aging well, in fact, is not just possible, but more common than not.
Unfortunately, the DOHMH report on healthy aging does not provide any measure of psychological well-being among older adults. For example, it would be useful to know how likely older adults in NYC are to experience life satisfaction and how this varies from neighborhood to neighborhood and from population to population. Is life satisfaction more common in affluent than poor areas of the city? Is it more common among whites than minorities?
It appears that the data sources used by NYCDOHMH do not provide adequate information about life satisfaction.
In addition to life satisfaction, it would be more than a little interesting to know about other psychological contributors to well-being, including a sense happiness, of meaningfulness, of security, of hope, of impact on one’s world, etc. Such an effort has recently been made in the United Kingdom, with interesting results, not the least of which is that “those aged 65 to 79 tended to report the highest average levels of personal well-being” 9.
What needs to be done? NYCDOHMH and other departments of public health should:
- Develop more comprehensive sources of epidemiological data, taking care to avoid ageist expectations.
- Pay attention to the full range of mental disorders and their impact on functioning.
- Pay attention to well-being in old age and to the psychological and social conditions that contribute to it.
We are very pleased that NYC DOHMH has focused attention on the health of older adults and at least touched on mental health and substance abuse issues. But it really needs to take a broader look at mental health as a critical component of healthy aging.
Michael B. Friedman is the Co-Founder and Honorary Chair for the Geriatric Mental Health Alliance of New York. He served on the advisory committee for the DOHMH Report, with little impact. He can be contacted at mbfriedman@aol.com.
Jaclyn Nguyen is a medical student at Johns Hopkins School of Medicine. She received her Bachelor of Arts in Spanish and Bachelor of Science in Human Biology from the University of Southern California. She can be contacted at jnguye47@jhmi.edu.
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013.
- Byers AL, Yaffe K, Covinsky KE, et al. High Occurrence of Mood and Anxiety Disorders Among Older Adults. Archives of General Psychiatry. 2010;67(5), 489-96.www.ncbi.nlm.nih.gov/pubmed/20439830
- 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? 2008. www.cdc.gov/aging/pdf/mental_health.pdf.
- Cohen C, Vahia I, Reyes, Pia, et al. Schizophrenia in Later Life: Clinical Symptoms and Social Well-being. Psychiatric Services. 2008;59(3), 232-234.
- Greer S, Adams L, Toprani A, et al. Health of Older Adults in New York City. 2019.
- Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies Press; 2012. www.aagponline.org/clientuploads/IOM%20July%202012%20Report%20Full.pdf.
- Kessler R, Berglund P, Demler O, et al. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(6):593-602. www.ncbi.nlm.nih.gov/pubmed/15939837
- Kessler RC & Wang PS. The Descriptive Epidemiology of Commonly Occurring Mental Disorders in the United States. Annual Review of Public Health. 2008;29(1), 115-129. www.ncbi.nlm.nih.gov/pubmed/18348707
- Office for National Statistics. Measuring National Well-being: At what age is Personal Well-being the highest? 2016. www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuringnationalwellbeing/atwhatageispersonalwellbeingthehighest. Accessed July 22, 2019.
- U.S. Administration on Aging Substance Abuse and Mental Health Services Administration. Older Americans Behavioral Health Issue Brief: Series Overview. 2012. www.ncoa.org/wp-content/uploads/Series-Overview-Issue-Brief-1.pdf.
- U.S. Department of Health and Human Services. Older Adults and Mental Health. In: Mental Health: A Report of the Surgeon General. 1999; 46-47. www.surgeongeneral.gov/library/mentalhealth/chapter5/sec1.html.
12 Wang P, Olfson M, Pincus H, et al. Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(6):629-40. www.ncbi.nlm.nih.gov/pubmed/15939840
** Some studies indicate that depression is more common than anxiety. Findings appear to depend on how “depression” and “anxiety” are defined in the studies.
* There is also a paragraph about alcohol use in the section of the report on health risks.
