The psychiatric needs of ethnic minority elders in the UK
Keywords: ethnic minority elders, mental health, psychiatric needs
The proportion of the ethnic minority population living in Britain who are over the age of 65 years has increased from 1% in 1981 to 3% in 1991 [1, 2]. The latter figure contrasts with 17% of the indigenous population aged over 65 in the same year . Most ethnic elders are first-generation migrants, with less than 10% being born in the UK . Almost 6% of the UK population aged over 65 was born outside the country . With the passage of time, the number of second-generation ethnic elders will increase and the number of first-generation ethnic elders will decline. However, these projections assume constant immigration and emigration trends and mortality rates in ethnic elders.
This increase in the ethnic elderly population will probably be associated with an increase in the quantity of psychiatric morbidity in this population. Psychogeriatric services will need to plan appropriately in order to provide a sensitive and accessible service for ethnic elders. This will require data on demography, social characteristics, epidemiology, presentation and natural history, pathways to care and availability and utilization of services and needs.
A heterogeneous population
The 1991 census provided data on ethnicity, age, social characteristics and geographical distribution. Afro-Caribbean elders have similar, household patterns to the indigenous elders, with many living alone [3-5]. Elderly individuals from Indian, Chinese and Vietnamese backgrounds usually live with several family members in the same household [3-6]. However, about one-quarter of Asians do not live with extended families [3, 7]. It is probably a myth that the extended family provides adequate care, although there are few data on this [9, 10]. Reasons why the extended family may not be able to provide adequate care include younger family members leading culturally different life-styles , younger family members working long hours and experiencing financial difficulties  and family tensions .
The effect of transcultural factors upon suicide rates illustrates this point. Suicide rates decline with age among Arabs , Indians  and Indian immigrants in Britain . However, suicide increases with age among the indigenous population. Traditionally, elderly people in these societies are respected and held in high esteem in a closely knit extended family setting. This persists in India [10, 11] and the Middle East, offering protection against suicide. However, suicide rates have increased in elderly women in Japan and Hong Kong who have lost their traditional role in the family . Physical proximity (living under the same roof) of the extended family is not important, but the emotional proximity is a key factor .
There is little information on whether the epidemiology and natural history of mental disorder among ethnic elders in the UK is similar to the indigenous population or the population of the country of origin. Research in this area has been hampered by diagnostic difficulties, lack of reliable and valid measures of psychiatric morbidity and the heterogeneity of the ethnic elderly population. The few studies of ethnic elders are biased because they are predominantly of individuals who have gamed access to services .
Reasons for diagnostic difficulties include: lack of reliable screening and diagnostic instruments [15, 16]; communication difficulties [15, 17]; absence of appropriate vocabulary to express symptoms of mental illness; `taboo’ topics such as sexual topics ; the stigma attached to psychiatry ; relatives being unfamiliar with symptoms of psychogeriatric disorders (as traditionally very few people reach old age ); and the bias and prejudice of the clinician .
There are no formal national or regional data on the use of health services, social services and voluntary services by ethnic elders. However, some data are available from small local and regional population surveys [4, 8, 18-20] including those conducted by Age Concern  and the Confederation of Indian Organizations . The uptake of health and social services by ethnic elders is poor [4, 8, 18-20]. Almost all elders and their carers from a range of ethnic groups were aware of services provided by general practitioners and utilized them effectively [3-5]. Data on the awareness and the utilization of secondary care services by ethnic elders are lacking. A survey of Asians of all adult ages revealed lack of awareness of where to go with emotional and social difficulties . No data, other than lack of awareness and utilization of community psychiatric nurses , are available for the use of psychogeriatric services by ethnic elders.
Ethnic elders are unaware of and under-utilize many social service resources [3-5]. Ethnic elders are underrepresented in nursing and residential homes. There is a similar lack of awareness of voluntary services including Citizen’s Advice Bureaux, Help the Aged, Age Concern and Dial-A-Ride [4, 5]. There are virtually no data on the needs of mentally ill ethnic elders.
Policy makers should commission research directed at developing reliable screening and diagnostic instruments and reducing communication difficulties as a prelude to formal cross-sectional and longitudinal epidemiological studies of prevalence, needs and natural history of mental illness among ethnic elders. Translated versions of the Mini Mental State Examination have been developed in Hindi , Chinese  and Gujarati . These could be adapted and validated for similar ethnic groups in the UK. Similarly, the Institute of Human Ageing has developed translated versions of the Geriatric Mental State Examination to examine prevalence of mental illness among older Chinese, Somali and Afro-Caribbeans in Liverpool . Development of valid and reliable instruments for screening and diagnostic purposes is likely to facilitate epidemiological research; this, in turn, is likely to improve identification of needs and development of services. Each service provider should collect systematic information on service usage by ethnic elders. The adequacy, availability and efficacy of interpretation services for those with mental illness also requires evaluation.
Public education campaigns may help reduce the stigma attached to psychiatry, improve the relatives’ knowledge of psychogeriatrics and reduce the bias and prejudice of some clinicians. Such public education campaigns can also make patients and their families aware of the available range of health, social and voluntary services. The Defeat Depression campaign (organized by the Royal College of Psychiatrists) and voluntary organizations for mental illness and for ethnic groups can have an important role here.
As almost all ethnic minority elders are aware of and utilize general practitioners, research and public education efforts should ideally be encouraged through (and in close collaboration with) primary care.
Many ethnic elders share certain common experiences on some issues (for example, language and communication difficulties). However, individual ethnic groups may differ from each other on other issues (for example, the ability to adapt and overcome the language and communication difficulties). The heterogeneity of ethnic elderly groups should be recognized in all the above endeavours and, where possible, amalgamation of different ethnic groups should be avoided: although research on an individual ethnic group may be more difficult, it is likely to produce more useful results .
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Received 11 June 1997
AJIT SHAH Department of Old Age Psychiatry, West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK. Fax: (+44) 181 321 5961
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