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Severe and enduring mental illness 

Severe and enduring mental illness
Severe and enduring mental illness

Catherine Hatfield

and Tom Dening

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This chapter addresses the needs of people growing old with long-term, severe mental illness. These comprise mainly patients with schizophrenia and other psychotic mental illness, but also a smaller number with bipolar affective disorder and other diagnoses including obsessive compulsive disorder, personality disorders, and substance misuse. Much of the clinical research concerns patients with schizophrenia, but the service considerations also apply to those with other diagnoses.

Historical Context

Graduates from institutional care

In the early part of the twentieth century, people with long-term functional mental illness in the UK were cared for in large county asylums. At the peak of provision in 1955 there were 152,000 inpatient psychiatric beds. From the 1960s onwards this model of care was questioned, as the disadvantages of long-term institutionalization became clear and bed numbers were gradually reduced, with a shift of focus to care in the community. By 1986 the inpatient population had halved and the old asylums began to be closed down (Jolley et al., 2004).

Older people with chronic psychosis were among the last to benefit from this new approach. In 1975 just over half of the 41,864 people resident in mental hospitals in England for more than 5 years were aged 65 and over (Department of Health and Social Security, 1978). In addition to the impairments associated with their illness they were further handicapped by their long hospital stay, which had left them with no independent living skills. (Clifford et al. 1991), surveying the population of five hospitals destined for closure, found that of those with functional diagnoses hospitalized for over a year, the mean duration of admission was 24.5 years and their mean age 64.5.

Nonetheless, studies, in particular from the Team for the Assessment of Psychiatric Services (TAPS) group studying a cohort of people discharged from Friern Barnet and Claybury hospitals, have found some positive outcomes. Only 71 out of 130 were alive 3 years later (not significantly different from those remaining in hospital) and, of those, half had returned to hospital. However, those remaining in the community had more social contacts and were more satisfied with their lives than those in hospital (Anderson et al., 1993; Trieman et al., 1999; Leff and Trieman, 2000). Even among those initially considered unsuitable for community placements, nearly half were able to be placed within the next 5 years (Trieman and Leff, 2002).

The Community Care Era

In 1990, the NHS and Community Care Act made local authorities responsible for providing appropriate community mental health services. This formalized the shift in attitudes over the preceding three decades. It was envisaged that people with chronic mental illness would live independently with support from community mental health teams and social care services and access mainstream education, leisure, and employment facilities. Unfortunately, not all of the expected benefits of community care were realized. The promise of integration into the community was not fulfilled and many former patients were merely ‘transinstitutionalized’ rather than deinstitutionalized, as they were moved into nursing homes that differed very little from the wards from which they had come. Services were criticized for being fragmented and failing to meet need (Killaspy, 2006). Between 1954 and 1996, 110,000 psychiatric hospital beds were closed and only 13,000 community placements replaced them (Lelliott et al., 1996). Some people with mental illness have undoubtedly been diverted to the prison or homeless populations (Priebe et al., 2005). Crane (1998) found that two-thirds of a sample of 219 homeless people aged over 55 from four UK cities suffered from a mental illness and that for at least 18% of them it was a factor in their becoming homeless.

Since the demise of the large institutions it has become harder to identify people with enduring mental illness, as they are scattered between different living situations and cared for by different services (if indeed they are receiving any service at all). This has led to them being all but invisible in terms of research and policy. The National Service Framework (NSF) for Mental Health (Department of Health (DH), 1999) applied only to working age adults. The separate NSF for Older People (DH, 2001) included mental health alongside physical health conditions, rather than as a main focus. The NICE guidance on interventions and management of schizophrenia (National Collaborating Centre for Mental Health, 2010) refers only to working age adults.


The adult psychiatric morbidity surveys in England found 1-year prevalence rates for probable nonorganic psychosis in those aged 65–74 of 0.4% in 2000 and 0.1% in 2007 (this compares to 0.5% for those aged 16–74) (McManus et al., 2009). Similarly in the US, National Comorbidity Survey Replication also reported a lifetime prevalence rate of 0.3% which fell to 0.1% among people over the age of 60 (Kessler et al., 2005). These figures are likely to represent an underestimate of the prevalence of older people with psychotic mental illness, both because of the exclusion of those living in institutional care and because even those living at home are unlikely to respond to surveys.

Smaller community surveys have given prevalence rates of 0.1–0.5%, including (Copeland et al. 1998) in Liverpool, Castle and Murray (1993) in Camberwell, and McNulty et al. (2003) in Lanarkshire. Regional prevalence figures will be affected by the historical structure of services, in particular the presence of large asylums in some areas. Rodriguez-Ferrera et al. (2004) found approximately half the number of cases in rural Suffolk as McNulty et al. in Lanarkshire and that a much higher proportion of subjects in their sample lived independently. They thought this was probably due to some patients being placed in the county asylum and not returning to their original area.

Prevalence rates in older people are much lower than the 1% lifetime prevalence usually quoted for schizophrenia overall. Some of the difference might be accounted for by incomplete ascertainment, but excess mortality due to suicide and physical ill health earlier in life are also major determinants.

Course and Outcome


The outcome of schizophrenia in older age is a contentious issue. Of necessity, the long-term studies needed to address this question encompass eras with differing diagnostic definitions, treatment options, and social contexts, and this makes their findings difficult to interpret. In addition, patients included in long-term observational studies have tended to be those institutionalized patients with a poorer prognosis.

Despite these limitations, long-term outcome studies of patients in the US and Europe followed up over 22–37 years have consistently shown that approximately half to two-thirds of patients achieve significant improvement or recovery in the long term (Bleuler, 1972; Huber et al., 1975; Tsuang et al., 1979; Ciompi, 1980; Harding et al., 1987; Marneros et al., 1992). The WHO International Study of Schizophrenia (ISS) provides particularly powerful evidence as it included 1633 patients from 18 centres around the world followed up over 15–25 years. Overall, 50% had a good outcome, increasing to 60% in some centres in the developing countries (Harrison et al., 2001).

Rates of recovery are dependent to a very large degree on the criteria used, specifically whether these are entirely symptom based or incorporate aspects of psychosocial functioning. The relationship of symptoms to function is not simple, as patients may develop coping mechanisms that allow improved functioning despite ongoing psychotic symptoms. There is good evidence to indicate that cognitive impairment is a better predictor of adaptive function than psychotic symptoms (Green, 1996; Velligan et al., 1997).

(Andreasen et al. 2005) proposed consensus criteria for defining remission of the absence or low intensity of eight core positive and negative symptoms sustained for a period of at least 6 months. They distinguished this from recovery which they conceptualized as a broader concept encompassing cognitive, functional, and psychosocial criteria. Recent studies employing these remission criteria in older patients have shown approximately 50% remission rates in two outpatient populations in the US (Bankole et al., 2008; Leung et al., 2008) but only 29.4% in a catchment area sample in the Netherlands containing both community-dwelling and institutionalized subjects (Meesters et al., 2011). Earlier studies employing stricter remission criteria found even smaller rates of 7–8% (Marneros et al., 1992; Auslander and Jeste, 2004).

A different approach to outcome is to ask people with schizophrenia about their subjective quality of life (QOL). Although there is no universally accepted definition of QOL the WHO defines it as ‘an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations and standards’ (Saxena and Orley, 1997). Health-related quality of life (HR-QOL) refers to the impact of a disease on a person’s wellbeing. Studies have found that older people with schizophrenia have lower HR-QOL than community controls (Patterson et al., 1996; Cohen et al., 2003). Depressive symptoms and cognitive impairment have consistently been shown to predict lower QOL (Cohen et al., 2003; Mittal et al., 2006). However, recent studies have suggested that mental health-related QOL actually improves with ageing despite reduced physical HR-QOL (Reine et al., 2005; Folsom et al., 2009). In a qualitative study, participants described reduced impact of symptoms and better self-management strategies with ageing (Shepherd et al., 2012).

Overall, it appears that whilst complete and sustained symptomatic remission is uncommon, this does not preclude a positive functional outcome (Cohen et al., 2008; Jeste et al., 2011). Most older people with schizophrenia remain symptomatic and impaired, but the course of the disorder appears largely stable, with no real evidence for either progressive decline or spectacular improvement (Jeste et al., 2003a). There may be even greater cause for optimism in the future as the cohort of people now entering later life with schizophrenia did not have the benefit of early recognition and effective treatment of their illness and were faced with even greater stigma and social exclusion than exists today. With reduced duration of untreated psychosis (Perkins et al., 2005) and avoidance of secondary disability, outcomes may improve still further for today’s cohorts.


Cognitive impairment

Cognitive impairment has long been recognized as a component of the clinical syndrome of schizophrenia. Semantic memory and executive functioning seem to be the most prominently impaired (Heinrichs and Zakzanis, 1998).

There is evidence that cognitive deficits are present at first episode and indeed may even predate the onset of illness (Jones et al., 1994), but whether these deficits remain static throughout life or continue to deteriorate over time remains controversial (Rund, 1998; see (Radhakrishnan et al. 2012) for a review). Cross-sectional studies of mostly younger community-dwelling patients with schizophrenia showed no deterioration in performance over time scales of up to 10 years (Heaton et al., 1994; Eyler Zorilla et al., 2000), although they were grossly impaired compared to normal subjects. In contrast, studies of older institutionalized patients have shown deterioration over time periods of as little as 2.5 years (Harvey et al., 1999; Friedman et al., 2001). Studies of long-term institutionalized patients may be confounded by the effects of institutionalization itself, use of long-term psychotropic medication, and selection for those with a poorer prognosis.

Pharmacological strategies to ameliorate cognitive dysfunction have not been successful to date. Antipsychotic medication has only a modest effect on cognitive impairment (Keefe et al., 2007), and apparent benefits are likely to be due to improvement in psychosis rather than in cognition per se. Indeed, antipsychotic drugs often have sedative effects that would tend to impair rather than improve cognition. Furthermore, despite some early promise in open-label trials, cholinesterase inhibitors have not been shown to be effective in randomized placebo controlled trials (Akhondzadeh et al., 2008; Lindenmayer and Khan, 2011).

Psychiatric comorbidity

Older people with functional mental illness are no more likely to have the neuropathological brain abnormalities of Alzheimer’s disease than the general population (Baldessarini et al., 1997; Arnold et al., 1998; Arnold, 2001). Even subjects with marked cognitive impairment do not show neuropathological abnormalities sufficient for a diagnosis of Alzheimer’s disease (Rapp et al., 2010). Given the high prevalence of dementia in older age groups, however, the conditions may co-occur.

It can be very difficult to distinguish the cognitive impairments associated with schizophrenia from a new onset of dementia. Short-term memory loss, word-finding difficulties, and disorientation are more associated with Alzheimer’s disease, whereas frontal executive deficits are more associated with schizophrenia. The time-course of cognitive decline should also be helpful in making the distinction.

Approximately 60% of people with schizophrenia suffer a major depression during the course of their illness and around a quarter experience depression following an acute schizophrenic episode (Martin et al., 1985). Depression is associated with poorer outcomes, including poorer response to drug treatments, longer duration of inpatient care, chronic course, and increased rates of relapse and suicide (Cohen et al., 1996; Siris, 2000; Jin et al., 2001). (Diwan et al. 2007) found that 32% of a community cohort of people over 55 with schizophrenia were clinically depressed versus 11% of controls. Depression was significantly associated with physical illness, positive symptoms, reduced number of confidants, and a coping strategy of medication use. Depression may be confused with negative symptoms but can be distinguished by the presence of low mood, early morning waking, and loss of appetite (Felmet et al., 2011). Although there is a paucity of evidence, there is reason to believe that treatment is likely to be successful. (Kasckow et al. 2001) demonstrated improvement in 19 chronically hospitalized patients aged over 55 with schizophrenia and depressive symptoms treated using citalopram in an open-label trial. (Zisook et al. 2009) also demonstrated improvements in mood, social functioning, and QOL in a double-blind randomized controlled trial of citalopram in 198 patients with schizophrenia and subsyndromal depression aged 40–75.

Substance misuse may become more of a problem as today’s cohorts age: rates of substance misuse amongst schizophrenic patients have been increasing over the past two decades, perhaps as a result of deinstitutionalization (Westermeyer, 2006). Dual diagnosis is associated with worse outcomes in terms of mortality, frequent hospitalization, and criminal offending (Schmidt et al., 2011).

Social exclusion

People with schizophrenia are less likely to marry and have children than the general population. About two-fifths never marry and a further quarter are divorced. Two-fifths do not have children (Cohen and Talavera, 2000). They are also less likely to have been in employment and their lives may be disrupted by substantial periods of hospitalization. All of these factors lead to them having substantially reduced social networks. Of those contacts that they do have, most are based on provision of sustenance or support (59% vs 15% for age-matched peers) and few are intimate, confiding relationships (44% vs 67%) (Cohen et al., 1996).

On measures of social skills they are significantly impaired in accepting and initiating contact with others, group participation, and making friendships (Bartels, 1997a). Social withdrawal may be a mechanism to cope with distressing psychotic symptoms, such as persecutory delusional beliefs or thought interference, or may result from reduced capacity to enjoy friendships due to negative symptoms.

Despite these deficits, older people with enduring mental illness do identify social needs as important. Auslander and Jeste (2002) examined the self-reported needs of a sample of 72 people (41–80 years). Around half of them lived independently and the remainder (47%) lived in an assisted care facility. The study excluded people with dementia or with a comorbid alcohol or substance abuse problem. The main priorities they identified were around social relationships (developing and sustaining friendships), managing their illness, and improvements in mood, physical health, and memory.

Physical health

People with schizophrenia have a two- to three-fold increased mortality rate compared to the general population and on average their life-expectancy is reduced by 10–15 years (Harris and Barraclough, 1998; Laursen, 2011). Much of this excess mortality is accounted for by suicides in earlier life, but there is also an excess of deaths from natural causes (Brown et al., 2000). There is an increased risk of death from cardiovascular and respiratory disease, infections, and type 2 diabetes (Jeste et al., 1996; Harris and Barraclough, 1998). This is likely to be multifactorial and related to lifestyle factors, side effects of medication, and reduced access to healthcare.

Patients with schizophrenia are more likely than the general population to have lifestyle risk factors for cardiovascular disease. They were found to be more likely to smoke, less likely to exercise, and more likely to have high fat, low fibre diets, even when the study population was controlled for socioeconomic status (Brown et al., 1999; McCreadie et al., 2003; Osborn et al., 2008).

Side effects of antipsychotic medication may also contribute to increased morbidity and mortality. The cardiovascular side effects of antipsychotic medication include lengthening of the QT interval which may contribute to arrhythmia and sudden cardiac death (Glassman and Bigger, 2001). Significant weight gain, dyslipidaemia, and new onset of type 2 diabetes are particularly associated with newer atypical antipsychotic medications. Conventional antipsychotic medications may significantly elevate prolactin levels, which interferes with sexual functioning and reduces bone density, increasing the risk of osteoporosis.

Patients with schizophrenia are less likely to receive treatment for physical health problems (Kilbourne et al., 2008; Vahia et al., 2008). Data from the Patient Outcomes Research Team (PORT) study in the US (Dixon et al., 2000) showed that 30% of patients reporting a physical health condition were not receiving treatment. Mitchell and Lord (2010) showed that following a myocardial infarction, patients with schizophrenia were less likely to be offered revascularization procedures and less likely to receive optimum medication regimes. Patients may lack the motivation to attend appointments, or cognitive deficits or delusional ideas may make it hard for them to comply with treatment plans, but is also likely that negative attitudes of care providers towards those with chronic mental illness play a role. Studies have shown that GPs were less likely to offer screening for cardiovascular risk factors to people with schizophrenia than to those with asthma or another diagnosis (Roberts et al., 2007).



There is a very poor evidence base to guide pharmacological treatment in older people due to their exclusion from large-scale randomized controlled trials (RCTs). Only two RCTs have been conducted specifically in older patients. One trial comparing olanzapine with haloperidol in 117 patients aged over 60 found that olanzapine was both more efficacious and better tolerated than haloperidol (Kennedy et al., 2003). A further RCT comparing olanzapine and risperidone in 175 older patients with schizophrenia found no significant differences between the two treatments (Jeste et al., 2003b). Older patients have been included in other trials, but the number of older subjects is either not specified or too small for meaningful subgroup comparisons.

Clozapine is the only antipsychotic medication shown to have greater efficacy in treatment-resistant schizophrenia (Kane et al., 1988) and has negligible risks of tardive dyskinesia (TD), but its use is tightly controlled due to rare but serious adverse effects including agranulocytosis, cardiomyopathy, and seizures. More common adverse effects include sedation and postural hypotension. There is very little evidence to guide its use in older patients and this is likely to become an increasingly important issue, as patients who were prescribed clozapine for treatment-resistant schizophrenia as young adults age. One RCT comparing it with chlorpromazine in patients over 55 found no differences between the two drugs (Howanitz et al., 1999). (Barak et al. 1999) reviewed the literature and identified 139 reports of patients aged over 65 treated with clozapine for a psychiatric indication. The mean dose used was 135 mg. Clozapine was discontinued in 25% due to side effects, noncompliance, or inefficacy and the rate of leucopenia was 5%. In the absence of any evidence-based guidance, it seems reasonable to make attempts at gradual reduction of clozapine dosage in older patients with psychosis.

Older patients would be expected to require lower doses of medication due to physiological changes associated with ageing. For example, there is an increase in the proportion of body fat with ageing which increases the volume of distribution of lipid-soluble drugs and prolongs their action; glomerular filtration rate decreases, reducing clearance of renally excreted drugs such as lithium; and liver metabolism may also be reduced, leading to increased plasma concentration of drugs such as benzodiazepines.

In clinical practice, one is often faced with the dilemma of weighing up whether to reduce antipsychotic doses as patients become older and frailer versus the risk of relapse of psychotic symptoms in someone who may have been stable for many years. There is little research evidence to guide decision-making, but in one study, (Harris et al. 1997) found that it was possible to reduce antipsychotic medication doses by about 40% in a sample of patients aged over 45 without an increase in symptoms. It is often possible to achieve significant dose reductions over time. How rapidly this is done depends on various factors, such as the potential severity of relapses, and also on the wishes of the patient, as some people will be more cautious about going on to a lower dose than will others. It is also often possible to replace depot injections with oral medication, especially if the person with schizophrenia is starting to receive personal care. This obviously makes it easier to assess the effects of altered dosages.

Older people are more susceptible to side effects from medication. TD is a particular problem with typical antipsychotic medications such as haloperidol and the risk is five to six times higher in older patients (Jeste, 2004). Studies of older hospitalized patients have shown very high rates of TD of 60–90% (Quinn et al., 2001). TD is often irreversible even after stopping medication, and although patients are usually not aware of the movements, they are obvious to others and can be stigmatizing. In severe cases, TD can cause difficulties with eating and swallowing.

Other common side effects are those related to anticholinergic actions, such as delirium, constipation, and urinary retention. All of these can be more severe in older people due to the interaction with physiological ageing. For example, prostatic hypertrophy in older men puts them at higher risk of urinary retention. In some cases, different side effects combine to increase the risk of an adverse outcome, e.g. antipsychotic medications cause both orthostatic hypotension, which can lead to falls, and reduced bone density, which increases the risk of fracture. Older people are also likely to be taking multiple physical health medications and this increases the potential for drug interactions.

Nonpharmacological treatments

There is now considerable evidence of benefit from cognitive behavioural therapy (CBT) in younger patients with schizophrenia (Tai and Turkington, 2009). It is recommended by NICE for improving persistent psychotic symptoms and increasing insight and treatment adherence and can be delivered in 1:1 sessions with a psychologist or in a group. Other psychological therapies such as social skills training and cognitive remediation have also been shown to be valuable in younger adults. Skills training is usually done in a group and may include learning about verbal and nonverbal communication and rules of social interaction using role play and exercises.

Recent studies have evaluated the effectiveness of combined interventions including elements of these therapies. (Patterson et al. 2006) developed functional adaptive skills training (FAST) and evaluated it in an RCT in 240 patients aged over 40. They showed significant improvements in social skills and activities of daily living and reduced use of emergency services in the intervention group. Granholm and colleagues (2005, 2007) also used a group cognitive behavioural and social skills training intervention (CBSST) in 76 older outpatients with schizophrenia or schizoaffective disorder, and showed significant improvements in social function and insight which were sustained over a year despite no improvement in symptoms.

In summary, the evidence suggests that older people are able to benefit from psychological therapies, but sadly in clinical practice these interventions are not yet widely available to older people.


From the 1970s and 1980s onwards, with the decline of long-stay wards and psychiatric hospitals, other types of provision have arisen to fill the void. Hostels and care homes run by private sector and voluntary organizations vary from those with 24-h staffing by qualified staff to those with daytime cover only from a smaller number of staff without specialist qualifications. Group homes are unstaffed facilities where small groups of residents with chronic mental illness live together supported by visits from staff (Macpherson et al., 2004). A more recent model of care is where each individual has his or her own flat or bedsit but within a unit where there is a staff member present and often some communal facilities. There is evidence that this form of support is preferred by patients (Tanzman, 1993).

It should not be forgotten that many people with enduring mental illness live with their families. (Tsai et al. 2011), examining data from the large Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study of outpatients aged 18–65 with schizophrenia in the US, found 46% living with family members (vs 18% living independently, 17% in an institution, and 14% with no stable housing). There are no corresponding national data for older people. These percentages will vary depending on cultural expectations and on provision of alternative resources. For instance, 60–80% of patients from ethnic minorities live with their families in the US (Lefley, 1987).

As people with enduring mental illness age, physical disabilities or loss of support networks may mean that their needs can no longer be met in their previous setting. (Andrews et al. 2009) studied admissions to nursing homes over a 10-year period in New Hampshire, US. They found a much younger age of entry to a nursing home amongst those with a diagnosis of schizophrenia (65 vs 80 for those with no mental illness). The rates of admission started to diverge significantly between the ages of 40 and 65 where nursing home admission risk was 3.9 times greater than for peers with no mental illness. The reasons for this are not known, but one could speculate that loss or burnout of the primary carer may have contributed. Bartels et al. (1997b) found that cognition, functioning, and behaviour were important predictors of nursing home as opposed to community residence, with cognitive impairment especially important as it was also a predictor of a person’s level of functioning. (Auslander et al. 2001) also found that among older patients with schizophrenia (age range 40–97), residence in assisted living facilities was associated with never having been married, the presence of cognitive impairment, and poorer quality of wellbeing.

Because their numbers are relatively small, those with functional illness are often placed in settings designed mainly for people with severe dementia that may be poorly placed to meet their needs. Opportunities for social interaction and participation in particular are likely to be severely limited and freedoms curtailed. These problems might be overcome by better staff education and individual care planning and risk assessment.

Psychiatric services

There has been much debate about who should provide services to older people with functional mental illness, and practice varies across the country. Patients may continue to be provided for by general adult or rehabilitation services indefinitely or they may automatically ‘graduate’ to the older people’s service on attaining the age of 65. In addition, some may have been discharged from or lost contact with secondary care and instead they receive their care from their GP and social care services.

People growing older with functional mental illnesses may perceive a great injustice in being discharged from services they have previously been able to access due to an arbitrary age cut-off of 65 years. Older people’s mental health services are often more poorly resourced than rehabilitation services for younger adults and focused around dementia rather than functional illness. Access to services such as crisis resolution and home treatment teams for acute relapses or assertive outreach teams may be restricted to working age adults. On the other hand, older people’s services may be better placed to meet the needs of those with physical frailty or cognitive impairment, whatever their age.

In the UK, the Royal College of Psychiatrists (RCPsych, 2002) published a joint report from the faculties of Old Age, General and Community and Rehabilitation Psychiatry which recommended that an individual’s health and social care needs should be regularly reviewed, that transfer should be based on need rather than chronological age, and that there should be agreed protocols in place. When this report was updated in 2009 (RCPsych, 2009), two-thirds of services that responded to a survey of policy implementation had transition protocols in place, but there was very little audit or data collection to demonstrate effectiveness (Bawn et al., 2007).

Services for younger people with enduring mental illness are now heavily influenced by the ‘Recovery Model’. This originated as a service user-led movement in the US in the 1990s but has now become a fundamental influence on mainstream mental health policy on both sides of the Atlantic (Silverstein and Bellack, 2008). It has aimed to redefine recovery away from a purely medical focus on remission of symptoms and towards the attainment of personal goals that provide hope, purpose, and meaning in life beyond mental illness (Anthony, 1993). Recovery-orientated services aim to promote shared decision-making, choice, and autonomy for service users. Social inclusion in mainstream employment and leisure opportunities rather than provision of segregated services is encouraged and peer support from those with lived experience of mental health problems is facilitated. Whilst these concepts are starting to be widely implemented in services for working age adults, there has thus far been little uptake in older people’s services. Nonetheless, some of the enshrined ideas around acceptance and hope seem applicable to the older age group too.

Mental Capacity

Lack of insight is very common and can lead to difficult decisions about whether a patient has capacity to refuse care or treatment and whether or when to intervene in a person’s best interests. The Mental Capacity Act provides a clear framework for making decisions, but in the case of older people with functional mental illness, the decision often hinges on the complex issue of their ability to weigh evidence and make a decision rather than on simpler issues of understanding or retention of information. Impaired decision-making capacity is not by any means a universal finding. In one recent study, 69–89% of subjects with psychotic mental illness were able to score in the same range as control or medically ill subjects on a test of decisional capacity (Candilis et al., 2008). Cognitive impairment is the best predictor of impaired capacity, but understanding can be improved by repetition of information (Moser et al., 2006; Palmer and Jeste, 2006).

Future Challenges

As the population ages, the numbers of people surviving into old age with enduring mental illness will increase. However, the numbers will always be relatively small in comparison to those with dementia, who form the overwhelming majority of patients of old age psychiatry services.

There are specific areas of expertise in working with older patients with long-term mental illnesses, e.g. around prescribing, medical support, housing and accommodation, and productive activities. Staff working within older people’s mental health services do need to develop this kind of experience and expertise and to have access to appropriate training and resources. This needs to be recognized in planning and providing services, with suitable arrangements for staff support and supervision.

The lack of research in this age group means that there is a dearth of good quality evidence to guide practice. More research in particular into medication, psychological therapies and services is urgently needed.


Older people with functional mental illness represent a vulnerable, marginalized group in society. Over the years, they are likely to have suffered invasive treatments, a lack of autonomy, and discriminatory attitudes. This history can increase their mistrust of healthcare professionals and they will often have no family members or friends to act as advocates or supporters. They may be the victims of a double discrimination on the grounds of age and mental illness and are likely to receive poor quality care despite having high needs.

Older people with enduring mental illness need access to good physical and mental healthcare, including screening and health promotion, given their high risk of physical ill health, psychiatric comorbidity, and drug side effects. Despite these challenges, positive outcomes are possible and older people should not be excluded from provision of innovative service models and psychosocial interventions.

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