1. Depression is the most frequent mental disorder amongst older people and af-fects up to 25% of the population, when less severe cases are included.
2. Depression is the major cause of suicide in older people. Males are at higher risk than females. In more than 90% of all countries the suicide rate is highest in the older age groups (over 75 years). Recent changes of this trend in some countries might be the consequence of social changes as well as those of pro-fessional treatments.
3. Major risk factors for depression in older people are disturbances and diseases leading to a reduced capacity to perform activities of daily living (for example a reduction in autonomy). Many of these risk factors can be prevented and/or tar-geted by special interventions.
4. Depression in older people is both a consequence of, as well as a reason for, a weakening of social networks. As a result, nursing home admission frequently occurs earlier and costly professional help is required more often.
5. There is a striking interrelation between depression and both chronic and multi-ple physical diseases. The presence of depression after stroke or myocardial
134
infarction (which occurs in more than 30% of cases) has been shown to be as-sociated with a significantly worse outcome and a higher mortality. Detection and treatment of depression in physically ill older people is, therefore, of major importance.
6. There are simple tools available to screen for depression and thus to enhance detection (e.g. the Geriatric Depression Scale).
7. Depression in older people is underdiagnosed and, as consistently shown in a variety of studies, less than a quarter of all patients get treatment, which again is often inadequate. The reasons for this are mainly:
· atypical presentation or “somatisation” of symptoms
· reluctance of the patient to accept a psychiatric diagnosis (and treatment)
· stereotypes that depression is “normal” in old age, which are shared by patients, doctors and society
· lack of training and education regarding geriatrics and mental disorders in physicians and other professionals working with older people.
8. When older people are given “state of the art” treatment, outcomes are as suc-cessful as for younger age groups.
9. Compared to depression, anxiety disorders in older people are almost ignored.
There is only a small data base on this topic.
10. Within the field of mental health, there is marginalisation of the disorders of de-pression and anxiety compared to the, admittedly necessary, public and scien-tific interest in the dementias, especially Alzheimer’s disease.
5.2 Description of the Process and Methods
The co-ordination of the older people sector of this project fell under the responsibility of the Mental Health Group of the National Research and Development Centre for Welfare and Health (STAKES, Helsinki, Finland) where four people were involved in carrying out the project: Professor Ville Lehtinen as the project leader, Dr. Juha Lavi-kainen as the project co-ordinator, Ms. Päivi Heikkinen (between 1 February and 30 September 2002) and Ms. Ulla Katila-Nurkka (from 1 January 2003 onwards) as sec-retaries.
The national partners were chosen from all EU Member States and the EEA Coun-tries. The recruitment of the partners was based for the most part on earlier contacts and networks. In the older people sector, a large number of internationally renowned experts in the field took part in the project. Moreover, a group of four people (Profes-sor Lars Andersson from Sweden, Dr. Riitta-Liisa Heikkinen from Finland, Profes(Profes-sor Gabriela Stoppe from Germany, and Dr. Judith Triantafillou from Greece), all highly experienced in working with older people in their countries, was selected as the ex-perts who would take part more actively in the sector's work.
The expert group (consisting of the project leader, the project co-ordinator and the four experts) convened once in Helsinki (on 18 November 2002) to conduct the final selection process of the best practices. Two additional meetings were held between the Finnish partners who participated in the two other sectors of the project. The pur-pose of the latter meeting was to screen the overall situation in Finland as well as to discuss relevant projects in each of the sectors. Such cross-fertilization provided to be very useful.
The principal objectives were common to all sectors: on one hand, the objective was to gather relevant information concerning the impact of anxiety and depression and related disorders and the management of these problems in relation to mental health promotion and prevention activities. On the other hand, the project aimed at identify-ing and evaluatidentify-ing strategies, projects and models of best practice from the partici-pating countries to develop a common strategy for coping with these problems. All information, including the individual practices and models, were collected by a ques-tionnaire, designed specifically for this purpose. Each sector aimed at finding some 15–20 models of best practice.
In all sectors, the collection of national projects was initiated through written guide-lines which were to be followed by the national partners and the staff of the sectors in order to carry out their tasks. The guidelines were produced and distributed soon af-ter the first meeting of national partners which was held in Brussels in February 2002.
Final versions of the guidelines and the questionnaires adapted by individual sectors were modified to best serve the differing needs of each sector. The deadline for
re-136
turning the completed questionnaires was the end of August 2002, leaving the na-tional partners with approximately six months to complete their part of the work.
The selection and evaluation criteria to be applied in this context were discussed a great deal. Optimally, the selected projects should be:
· multi-professional
· multi-method
· assessed
· running for at least two years
· evaluated
· sustainable
· replicable.
It was decided that according to the differing nature of the sectors, the criteria for all three of them need not be uniform. Therefore, concerning the evaluation of the proj-ects, a decision was made in the sector of older people that the selected projects should
· be relevant to the theme of the project,
· have been completed, and
· have undergone a reliable evaluation.
5.3 Outcomes and Selected Best Practices
This section provides first a quantitative summary of the questionnaires14 received and continues with a short description of the selected best practices.
The national partners from 12 countries delivered in total 47 questionnaires15. The resulting information was collected from questionnaire 2, the aim of which was to re-port in detail the national projects on mental health promotion and prevention of
14 At the beginning, the project also aimed at tackling the economical aspects of mental health prob lems. The intention was to collect the relevant economic information by another questionnaire, but it turned out that this type of information was not readily available in most countries.
15 Some of these questionnaires arrived too late to be included in the selection process with the perts.
mental health problems focusing on Older People16. From these questionnaires, 20 best practices were chosen by with the expert group.
COUNTRY
Number of proj-ects
Selected best practices
Austria 2
-Belgium 6
-England 11 5
Finland 7 2
France 2
-Greece 3 3
Iceland 1
-Ireland 1
-Italy 1 1
The Netherlands 3 3
Norway 6 4
Sweden 4 2
TOTAL 47 20
The collection for proposals for best practices must not be regarded as a compre-hensive selection of all available practices in the Member States. Much has de-pended on the activity and personal interest of the national partners
The lack of projects from some of the Member States may have had many reasons ranging from absence of relevant projects in the particular country, through organiza-tional restructuring in the middle of a project leading to a difficulty in finding a re-placement, to personal reasons for the national partners not being able to complete the work. Unfortunately, some of these problems were only uncovered at a rather late stage of the project, thus excluding the possibility to try to find a replacement national partner.
It was, however, of interest to observe largely similar projects within two (or more) individual Member States (this was the case in projects such as help for the carers of Alzheimer patients, centres for elderly, and decreasing loneliness and supporting in-dependent living by e.g. home visiting and befriending services).
16 Questionnaire I, which was aimed at providing information about mental health promotion activities in general and the economic aspects of mental health, social capital etc. was received from 11 coun tries.
138
Thematically, the projects may roughly be divided into four categories:
1) prevention of loneliness and isolation, 2) coping skills training,
3) community approaches and 4) care unit interventions.