Age, ethnicity, and mental illness: a triple whammyBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7069.1347 (Published 30 November 1996) Cite this as: BMJ 1996;313:1347
- Greta Rait,
- Alistair Burns,
- Carolyn Chew
- Clinical research fellow Professor of old age psychiatry University Department of Old Age Psychiatry, Withington Hospital, West Didsbury, Manchester M20 8LR
- Senior lecturer University Department of General Practice, University of Manchester, Manchester M14 5NP
We need validated assessment instruments for specific communities
A major public health issue for the next century is the increase in the number of elderly people from ethnic minority groups. The large numbers in the 40–64 year old cohort will soon be in the over 65 group, which is traditionally associated with particular health, social, and economic needs.1 2 3 Attention has tended to be focused on the physical health of these groups,4 and this, together with the traditional stigma of mental illness, has led to relative neglect of the mental health of older people from ethnic minorities.
Up to 15% of elderly people are known to suffer from depressive symptoms, of whom one third have an illness requiring treatment, often associated with physical illness.5 Prevalence rates for dementia range from 1.1-2.2% in those aged 65–69 to 31.6-36.0% in those aged 95–99.6 The equivalent figures can only be estimated in ethnic minority groups, especially since they are underrepresented in their use of secondary services such as psychiatric outpatient clinics. This may be due to a low prevalence of illness, lack of presentation, lack of detection, lack of referral, or any combination of these.
Elderly people from ethnic minority backgrounds are heterogeneous communities.7 The assumptions held by society about community strength, extended families, and informal support may be both false and racist.8 “Double jeopardy” has been used to describe the double challenge of racism and agism faced by people from minority backgrounds,9 and socioeconomic deprivation has been added to form “triple jeopardy.”10
Existing instruments for screening for depression and dementia were developed for use in the indigenous white population. Western ideas of distress and symptoms are not necessarily true for other ethnic groups, and it is difficult to translate emotions into English even if language skills are honed or an interpreter is present. For example, symptoms described as “pressure in the head” could mean stress or high blood pressure; “aching all over” could be a rheumatological symptom or may convey distress. Research has shown that the results of formal screening tests are less valid for people of different cultural backgrounds, lower literacy, and educational attainment.11 12
The NHS research and development programme has funded a project based in general practice to validate screening tests for depression and dementia in elderly subjects from ethnic minorities, assess their acceptability and reliability, and document service uptake and user expectations. The project aims to provide reliable and valid instruments that could be used in the community and provide data for use in epidemiological studies. The study will use community focus groups to help modify present screening tests, creating culturally relevant and acceptable instruments. A formal translation process will ensure that translated material is sensitive and accurate.13 14 This information will allow us to provide services that are appropriate to actual rather than perceived need.
Without valid instruments we cannot perform the necessary assessments in ethnic minority communities, and without such assessments the size of the problem will remain hidden. The result will be crisis management, which is both unsatisfactory and inexcusable. The individual elements of the triple jeopardy can be tackled in isolation—but the real challenge is to unravel the complex interaction of the three elements.