Under the radar: BME mental health

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Language barriers and stereotyping mean the mental health needs of black and minority ethnic older people are going unseen by commissioners. Kaye McIntosh reports

Older people from ethnic minority backgrounds with mental health problems face the triple whammy of discrimination arising from their age, their ethnicity and their psychological ill health.

But this is a group the NHS cannot afford to neglect. The older black and minority ethnic population is growing fast and is expected to increase by 170 per cent from 2005 to 2012, according to the recent UK Inquiry into Mental Health and Well-Being in Later Life. The inquiry, led by Age Concern, warned that older BME people are among the groups most likely to suffer from mental health problems.

But it is hard to be exact about figures for the prevalence of mental health issues such as depression or dementia among such groups.

"It is so varied according to different communities," says Help the Aged senior health policy officer Charlotte Potter. She quotes a study set in Liverpool that estimated levels of depression range from 19 per cent in black African elders (above the rate for the general population) to 13 per cent in Chinese elders (below the average).

Yolande Watson, health project manager at the Policy Research Institute on Ageing and Ethnicity, says the lack of data means "there is little strategic or policy perspective at the moment".

That creates a vacuum where the NHS often fails to pick up the needs of these groups, she adds. Older BME people "are not on the radar of the commissioning process". And what little data exists "is not feeding through into strategic needs assessments for psychological therapies and service pathways or workforce planning".

While a national, comprehensive focus is lacking on these issues, there are numerous small voluntary groups carrying out individual projects up and down the country.

The Care Services Improvement Partnership found more than 100 different groups offering a variety of services, from a Chinese community centre in Leicester to a dementia cafe for black elders in Leeds and the Asian Elderly Women's Support Group in Dudley (see below). The groups tend to concentrate on maintaining well-being rather than offering crisis intervention.

But Age Concern policy officer for BME older people Claire Ball says there is no central pooling of knowledge and experience.

"Very often the issue for BME voluntary and community sector organisations is about joining up and learning from each other, sharing resources to develop a systematic approach and monitoring inputs and outputs. If we could support a common framework for maintaining mental health and well-being, that would help to demonstrate the value of the work people are doing."

There are also very real barriers to people accessing services, including language.

Ms Ball says: "In some communities there are no words to describe some mental health conditions. There is no word for dementia in five South Asian languages, for example."

Present and correct

Ms Watson says the way BME people present can be very different from the mainstream. Depending on the particular community background, this could be using the language of "similes and symbols".

Nadine Schofield, national lead for CSIP's mental health in later life project, says people are often afraid to seek support outside their own family or community as they feel ashamed or fear being misunderstood.

Ms Ball adds that social isolation is a significant issue across BME communities but particularly in some areas. Women in South Asian communities who don't speak English may struggle "to handle life outside the home" - after bereavement, for instance.

Assumptions by those who commission and provide healthcare are barriers, too. Ms Watson explains that "people stereotype cultures. With South Asians, there is an assumption that they look after their own." But the younger generation might have moved away from their parents' home, or may not want to meet this expectation.

"I would ask the NHS to look at the needs of the individual," she adds.

Even when someone does speak up, they may not get the right kind of help. Talking therapies may be more useful to some cultures, but they are generally not offered as first port of call to elders from BME communities.

Ms Watson warns: "The increasing access to the psychological therapies programme is pushing the cognitive behavioural therapy agenda. It is action-oriented but that might not be appropriate for people from different communities."

NHS organisational silos can also get in the way of stakeholders trying to inform mental healthcare for BME older people. Several sources in the third sector related experiences of being batted between PCT diversity teams and mental health service delivery departments, each saying the other one should handle the issue.

So what can NHS commissioners or providers do to create more culturally sensitive services? Ms Schofield says it is about outreach, harnessing the knowledge and experience of voluntary groups and older people themselves, but warns: "It takes time to access these communities and win trust."

It is about far more than translating leaflets into community languages, she argues. "This has got to be the nuts and bolts of what people in those communities say they want."

Ms Watson agrees on the importance of outreach. The Policy Research Institute on Ageing and Ethnicity has been supporting NHS organisations in West Yorkshire to run half-day sessions on referral pathways in depression and dementia for voluntary sector groups that provide day care, self-help and advocacy services. "Community partners need to understand access points for psychological therapies," she says.

Local authorities and NHS commissioners could also help third sector organisations within the BME community write tenders for services, Ms Watson adds. These small groups are unable to jump bureaucratic hurdles but are experts in the needs of their community.

Challenging assumptions

"Commissioners and providers need to analyse their local populations [and] not assume everyone from South Asia is the same," comments Ms Schofield.

The Care Services Improvement Partnership funded five community groups to develop culturally appropriate resources that promote understanding of elders' experiences of depression, reduce stigma and identify pathways to support. It has also produced a guidebook for practitioners and voluntary agencies and is drawing up guidance for commissioners.

Commissioners could offer sustained core funding to community groups to build capacity in the community, the guidance suggests. It calls for better data collection about the needs of BME elders as well as a whole-system analysis with shared performance indicators across health, social care and housing to help understanding of the complex, interlinking issues.

Identifying unmet needs and creating truly culturally sensitive services is not a simple exercise but there are people and resources that the NHS could call on.

The Caribbean dementia cafe

Leeds Black Elders Association is a community group that runs a club for carers and people with dementia. It offers activities geared around recollections of the West Indies, for people who live in the community and those in residential care. Project worker Audrey Johnson says that while short-term memory may be lost, "long-term memories of the old days are still there".

Activities include playing the right kind of music - gospel and Jim Reeves - to provide reminders of the past, as well as serving traditional Caribbean food such as goat meat with boiled rice. This is much needed because other statutory service provision just does not appeal to this community, says Ms Johnson. "We serve high tea with alcohol because Caribbean elders want to party!"

The dementia cafe also gives carers some respite, although many choose to stay to take part in the activities. Around 48 people use the cafe every month. It is staffed entirely by volunteers and receives no statutory funding.

Asian day centre in Bristol

The Asian Health and Social Care Association in Bristol runs a day centre for elderly South Asian people. It has 120 members from a range of communities, including Hindus, Sikhs, Pakistanis and Bangladeshis. Clients include people who are lonely, isolated or forgetful, as well as those with dementia or depression.

The centre provides a range of activities from counselling and day trips to visits from Age Concern and the local primary care trust to explain which services are on offer.

Healthy vegetarian meals are an important part of the appeal to users and preventive healthcare includes massage and keep fit sessions.

"No one sits in front of the telly unless the cricket is on," says centre manager Amarjit Singh.

Funding is always a struggle for the centre, which survives on just £72,000 local authority funding a year and has recently been cut by 3 per cent.

The centre has a long waiting list of people it does not have the capacity to help.

Find out more

Care Services Improvement Partnership, www.olderpeoplesmentalhealth.csip.org.uk

Policy Research Institute on Ageing and Ethnicity, www.priae.org

Delivering Race Equality in Mental Healthcare, www.actiondre.org.uk