This article first appeared in The Edge Malaysia Weekly on October 26, 2020 - November 1, 2020

Many today still find it difficult to talk about mental health, despite an increase in societal awareness on the matter. This is true particularly among the senior community who struggle to overcome long-held personal and cultural beliefs.

Joan Low, founder and CEO of ThoughtFull Hub PLT, says awareness of mental health has improved over the past few years as a result of more conversations on the topic, thanks to the rise of social media whereby individuals have been empowered to share their stories with a mass audience.

She adds that it is unsurprising that much of these conversations have been driven by the younger, digitally native generation, but the trend has also been growing among the older generation.

While progress has been made in raising society’s awareness of the importance of mental health, there is still a long way to go, especially when it comes to addressing the stigma that prevents individuals from increasing their mental health literacy, says Low. This literacy involves — but is not limited to — the understanding of how to obtain and maintain positive mental health as well as how to treat issues related to it.

“Preconceived ideas and misconceptions need to be addressed as it is made more complex when cultural, religious and traditional layers serve as influencing factors. This is especially prevalent among the silver generation,” Low stresses.

“However, there has been more concerted effort from governments and private sectors alike to address mental well-being as a whole since the Covid-19 pandemic.”

Association of Private Counsellors (Counselling Psychology) president Johana Johari shares that while there is more conversation about mental health now compared with 30 years ago, the habit of not talking about their problems with anyone outside of their family is deeply ingrained in baby boomers. Baby boomers were born between 1946 and 1964. They are currently between the age of 56 and 74.

Meanwhile, most of them would feel like they have failed their children if the latter were to seek help from a mental health practitioner. “For them, it would be as if their child had just dropped a bombshell and they would feel guilty [about it],” says Johana.

In fact, two in three seniors experience mental health symptoms but they choose to believe that their condition is not serious, she reveals, adding that public information on mental health is not primarily aimed at this age bracket.

“They feel it’s a [problem faced by the] younger generation. About one in 20 of our patients is a boomer. It’s not a good ratio and we hope more will come in [to seek help]. But if they do come in, it would usually be because their children had encouraged them to do so. This is the only exception we make where we will accept third-party bookings, otherwise we would not.”

Gan Pooi Chan, country manager of home care services company Homage Malaysia, says there is still a stigma attached to mental health issues, more so for seniors as they were taught in the past to shun individuals with mental conditions lest they end up in the same boat. She adds that afflicted individuals suffer in silence because they do not want to be a burden.

“However, more family members — especially those who are caring for their parents — and seniors are going through this journey of understanding the importance of mental health together, by taking the first step to seek professional help without judgement and discrimination.”

Alzheimer’s and dementia are the most prevalent mental health conditions seen among seniors. According to a 2017 World Health Organization (WHO) report, about 15% of adults over 60 suffer from a mental disorder. The most common mental and neurological disorders in this age group are dementia and depression, which affect about 5% and 7% of the world’s older population respectively.

The 2015 National Health Survey in Malaysia showed that the prevalence of mental health problems in patients aged 60 and above was 24%. Singapore is experiencing a high suicide rate of 10 in every 100,000 senior citizens between the age of 60 and 64. Meanwhile, in India, almost half of the elderly patients have a significant overlap of depressive and anxiety symptoms.

Johana says in her 26 years as a counselling psychologist, she has seen most seniors struggle with their spiritual system and existential angst. While some psychologists may say that psychology is enough to help the seniors, she believes that their spiritual needs should not be ignored.

“I had a client who had just retired and his brother had died from cancer. He was raised a Buddhist and his wife was a Christian but he didn’t subscribe to either set of beliefs. We had to explore what it was that he believed in and what he was comfortable with. When he decided on a set of beliefs, he was able to find some form of serenity.

“It also helped that he knew, understood and chose to believe in how his afterlife was going to be. They (the older generation) [tend to] go through existential angst — when they worry and are anxious about what they believe in and where they will go in their afterlife,” Johana explains.

“They see people their age around them who have passed away, so they would definitely begin to think about their own mortality.”

ThoughtFull’s Low says when it comes to seeking treatment, there has been a surge in seniors seeking help compared with five years ago, especially since there have been various government initiatives to promote awareness and increase accessibility of mental health services. Despite the increase in numbers, by and large, these services are still underutilised by the silver population, she adds.

“[This is] due to, among others, financial inaccessibility for sustained usage of such services, especially when they may not have adequate insurance coverage. As mental health awareness and literacy among this group is still nascent, it is not uncommon for other physical chronic conditions to take precedence during a primary care visit, leaving their mental health unchecked,” Low points out.

She shares that according to Mental Health America, only 38% of adults over 65 believe that depression is a “health” problem. When it comes to depression, older adults are more likely to “handle it themselves” and only 42% would seek help from a health professional. About 58% of this population hold to the belief that depression is synonymous with ageing, and thus do not bring it up with their friends, family or primary care providers.

The first Malaysian psychogeriatric unit catered for the silver population was established at Hospital Sultanah Aminah in Johor in 1998. While the field has seen growing interest since then, Low says the number of local mental health professionals with expertise in geriatrics is still insufficient to meet the national needs, thereby making treatment tools and services less accessible to seniors.

She adds that as at 2018, there were only 10 specialised psychogeriatrics (psychologists for the elderly) recorded in the country, with a professional to population ratio of 1:20,000 — a far cry from achieving the WHO’s recommendation of 1:10,000.

“Due to the lack of manpower, the role of caring for the mental health of the older population is largely borne by physicians or psychiatrists,” says Low. “Additionally, the lack of awareness and knowledge of elderly mental health issues hinders the expansion of support systems to include families and the general public.”

According to Low, there are two important elements that will help make mental health services more accessible and effective. The first is to increase the number of service providers catered for the older population. The second is to ensure that mental health literacy levels among the elderly and their caregivers are sufficient, so that both parties recognise the benefits of being open about one’s mental well-being.

“Allocating resources to train competent mental health professionals whose expertise cater for the silver population would be an important step towards providing them with greater access to mental health treatment and services,” she says.

“Additionally, the use of digital mental health platforms like ThoughtFullChat will provide increased personalised support to caregivers and the older population by connecting them with certified professionals for daily consultations, recommendations and mental health education.

“Through digital solutions on smart devices, users can access mental health services from remote areas, during odd hours of the day, or even while on the move. This may be ideal for those who have trouble with in-person appointments.”

Johana has been caring for her mother who has been diagnosed with Alzheimer’s. She has seen signs of improvement in her mother after her mental health needs were addressed using the biopsychosocial method. This starts with identifying the medication that is consumed regularly as it may have mental health side effects such as depression and anxiety.

“I look at their biological issues, then their psychological issues and then their social

support system. Biological issues include their sleeping patterns and whether there are any other deficiencies in their body, such as magnesium and calcium. They’re probably eating food that tastes nice but are not good for the body and brain,” Johana explains.

Regardless of one’s age, she says to maintain good mental health, one needs to allocate time for doing something that brings joy, on top of getting enough sleep and having a good diet. By doing this, one will be able to rid themselves of boredom, she adds.

“Dealing with depression, anxiety or loneliness requires us to engage or connect with something that is outside of us, so that it becomes an outlet for any anxiety or loneliness. This is even more important for baby boomers, as they were asked to grow up very quickly. They missed out on their childhood, so if they can, they should allow themselves to indulge in activities that would make their inner child happy.”

Meanwhile, Homage’s Gan says there are many ways of preventing mental health illnesses and sometimes, external tools are not necessarily needed. For example, she says brain exercises help with keeping the mind alert, so having social activities such as morning walks with neighbours help with mental wellness.

“Even in isolation, one can always start with social interaction through video calls to family members and friends. Light physical exercises have also been shown to help alleviate some of the impact of mental health issues and to work the brain muscles. Seniors can also take on mental activities like jigsaw puzzles, sudoku and chess to keep their mind active. Underrated activities such as reading or writing not only help with creativity but also improve memory functions and language skills.

“This applies to both prevention and the slowing down of the progress of existing mental health conditions,” she says.

Gan points out that seniors may not know how to seek help or who to reach out to for help. Many fear that any form of intervention will result in them being a burden to their children, so they often carry with them a sense of guilt and helplessness.

“Another reason would be that they lack the financial resources to seek the long-term support they need. It is very important to first create conversations between seniors who are going through the same issues. Only by sharing their experiences will they come to the realisation that they are not alone in this.”

At the end of the day, a lot still needs to be done to tackle mental health issues among seniors, especially since the world’s population of older adults is expected to double in the next 30 years. Low says at Thoughtfull, they encourage family members, caregivers and seniors to be open about their mental health concerns in order to establish a strong foundation for a healthier ageing population.

“It is also crucial for family and caregivers to first be educated on common mental health challenges among seniors. It may be the starting point in creating discussions that promote healthy supportive strategies while encouraging help-seeking behaviours, and generally [talking more about issues] surrounding mental health. Information can be delivered via websites or mobile apps to improve access to information regarding seniors’ mental health.

“If you suspect that your loved ones are struggling with mental health issues, do get in touch with your healthcare provider. They may direct you to psychiatrists, psychologists or counsellors who can help. The silver generation can benefit from a strong sense of support from their healthcare providers, family and friends in times of need,” says Low.

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