rehabinkmag Commentary, Issue 13

Reworking Mental Healthcare in Ontario Long Term Care Facilities

Image by Hannah Spencer-Thompson for RehabINK

Commentary

By Ilakkiah Chandran

The current COVID-19 pandemic has introduced and exacerbated global challenges to people’s day-to-day functioning and overall well-being. Ontario rolled out public health policies to reduce the spread of this virus; however, they often failed to address health holistically (1). Although mask mandates, visitor restrictions at long-term care (LTC) facilities, and social distancing measures supported the prevention of spread, they often introduced challenges to peoples’ mental health and cognitive wellbeing. Amongst the many groups that experienced these challenges, older adults reported increased loneliness, anxiety, and chronic stress (2,3,4). These symptoms are often associated with an increased risk of mental illnesses such as depression, post-traumatic stress disorder, and generalized anxiety disorder (5). Increased mental health challenges amongst older adults, specifically those in LTC facilities, have been an ongoing concern worsening during the pandemic, indicating the necessity of immediate intervention (6). As vaccine rates increase and public health guidelines ease, it’s time to focus our efforts on rebuilding and introducing more robust systems to support the well-being of older adults in LTC facilities. This commentary will discuss barriers to mental health care in LTC facilities and propose practical recommendations to address this critical issue.

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Background

By 2036, approximately 23% of Ontarians will be above 60, with about 40 percent of older adults experiencing mental health problems (7,8). In Ontario, mental illnesses experienced by older adults include depression, dementia, and anxiety disorders (8). This significantly affects their health by worsening existing chronic conditions (i.e., diabetes, cardiovascular diseases), impacting physical well-being, exacerbating their cognitive functioning, and more (8,9). Previous literature indicates that successful ageing is closely tied to mental health as it constitutes being healthy across all aspects, including physically, mentally, and cognitively (10,11). However, the increased incidence of mental illness and the lack of efforts focused on mental health promotion in LTC facilities raise concerns.

In addition to the existing problems, the COVID-19 pandemic exacerbated mental health challenges experienced by older adults, specifically those residing in LTC facilities (9). Given that older adults are at increased risk of severe illness from COVID-19, the Ontario government imposed strict screening measures and visitor restrictions, limiting new resident admissions and preventing residents from leaving the facilities (9). Although these restrictions were imposed in hopes of protecting older adults residing in LTC facilities, residents reported increased feelings of isolation, psychological distress, and anxiety (12). Furthermore, a recent study conducted by Flint et al. found that LTC facility residents did not receive mental health care support during the pandemic (13). This brings to question the longstanding neglect of mental health care in LTC facilities. Moreover, it also highlights the barriers to mental health care in LTC facilities, such as the gaps in training and lack of accessibility. It focuses on the residents’ experiences with mental health.

Problem

Based on the literature mentioned above, mental health care is not prioritized for older adults in LTC facilities both before the pandemic and now. Research suggests that although more than 80% of LTC residents have a mental illness; residents are not receiving the care and treatment they need (8). The lack of care, treatment and support can be attributed to reduced accessibility of services (15,16), lack of efforts focused on the stigma of mental health among older adults (8), and the biomedical model’s use in training health care practitioners and personal support workers (PSWs) (17). One of the critical issues with the current efforts lies in the lack of accessibility of services. A study from 2019 that assessed psychiatric service delivery in LTC facilities revealed that amongst the 27,650 residents who demonstrated psychiatric need, only 3,175 received any support within 90 days (15). This study also revealed that greater service delivery was correlated amongst residents who were male, younger, achieved higher educational status, had a previous psychiatric history, and earned a higher previous income (15). This difference in service delivery demonstrates inequities amongst LTC residents (15). There is also a shortage of geriatric psychiatrists in Canada, indicating a lack of trained staff who can support older adults in LTC facilities while assessing and treating their mental illnesses (16). The inadequacy of mental health care service delivery raises concerns regarding the accessibility and effectiveness of LTC facilities’ mental health practices.

Another critical issue with the current efforts is the lack of emphasis on self and social stigma and health literacy that led to the late identification of mental illnesses. The Canadian Mental Health Association of Ontario suggests that social stigma (i.e., stigma from others based on their identity) and ageism make it difficult for older adults to speak up regarding their mental health, perpetuate self-stigma (i.e., stigma one feels about themselves) preventing them from accessing assessments, mental health services and treatments (8). Previous research suggests Ontario LTC residents with depression often show worsening symptoms over three months; older adults are at greater risk of experiencing prolonged effects of their mental illness without early detection and treatment (8). Therefore, older adults’ experiences with ageism, self and social stigma limited access to health literacy may perpetuate this risk.

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Furthermore, current health care practitioner and PSWs training lack emphasis on a holistic and interdisciplinary model, ultimately discounting the importance of mental health (17). Critiques of current health care training state that there is increased emphasis on the biomedical model, which neglects the mental and cognitive wellbeing of patients (17). The use of a biomedical approach fails to acknowledge mental health as a component of well-being and increases its stigma. Given that older adults residing in LTC facilities depend on their PSWs to support them through the challenging times, the lack of mental health training PSWs undergo to equip them to handle this. Ultimately, the inadequacy of mental health services to older adults residing in LTC facilities can be attributed to the lack of structural and systemic efforts calling for immediate action.

Recommendation

“Improving mental health care and services for older adults in LTC facilities requires a multi-faceted approach.”

Firstly, the accessibility of services must be increased equitably and efficiently. Including mental health professionals (i.e., psychologists, social workers, counsellors) in the primary care team of residents will ensure regular mental health assessments and improvement of service equity. Previous research indicates that a multidisciplinary team consisting of mental health practitioners helped facilitate communication and the development of effective treatment plans for residents (18). Furthermore, an interdisciplinary team will ensure the provision of health holistically rather than biomedically alone.

Secondly, given a shortage of geriatric psychiatrists, all staff working in LTC facilities must complete Ontario-wide standardized mental health training to provide adequate support and services to them. Previous use of standardized mental health training for mental health nurses yielded increased risk assessment of patients, developed feasible treatment plans, and increased mental health awareness (19, 20). Therefore, implementing standardized training can improve the quality of care, enhance early intervention, and reduce stigma amongst staff.

Additionally, implementing peer support groups within the facilities can diversify the support offered while improving the self-stigma residents may experience. Researchers identified that increased isolation perpetuated stress amongst residents and suggested that implementing such groups can increase belongingness and promote coping strategies (13). Thombs & Carboni-Jiménez argue that training older adult volunteers to support those in LTC facilities can encourage social-wellbeing and be as effective as professional support (14). Hearing about the experiences of one another may improve self-stigma and promote awareness and help-seeking behaviours amongst residents (21).

Although these considerations may improve the mental health care provided to older adults residing in LTC facilities, there are some limitations to the proposed considerations. Utilizing standardized training across Ontario may not effectively inform staff of the diversity in mental illnesses, symptoms, and the course of the disease. To reduce this limitation, facilities should regularly update training and provide additional resources to staff. For example, LTC personnel should be trained in Psychological First-Aid specific to older adults and be provided with resources on identifying mental distress amongst residents and communication strategies to support their conversations with older adults (22). Furthermore, ensuring a team of health professionals build training on diversity (i.e., the inclusion of experiences from people of colour, LGBTQ+ and Indigenous individuals) may improve its applicability. Another concern that may arise is the cost of implementing interdisciplinary teams at LTC facilities. It is important to note that mental health is an essential service. In-depth discussions with the Minister of Finance and other professionals can support developing a sustainable and feasible plan that ensures the prioritization of older adults’ mental health in the LTC facility service delivery.

Conclusion

In conclusion, older adults residing in LTC facilities require appropriate and effective mental health services. Improving the accessibility, quality and delivery of mental health care involves implementing interdisciplinary teams, standardization of mental health training, and promoting awareness amongst residents. Although there are some limitations related to costs and equity considerations, ensuring sustainable and equitable planning with the respective professionals can mitigate these concerns.

Acknowledgements

Featured illustration by Hannah Spencer-Thompson for rehabINK.

To refer to this article, it can be cited as:

Chandran I. Improving Mental Health Care for Older Adults in Long Term Care Facilities. rehabINK. 2022:13. Available from: https://rehabinkmag.com

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