Maintaining mental health in later life: the effectiveness of low-intensity psychological interventions and factors associated with mental health literacy in rural-dwelling older adults
Cremers, Gwendolyn Erin
Background: Older adults are less likely to access mental health services than younger adults despite experiencing similar rates of mental health problems. Older adults experiencing mental health problems are more likely to be offered medication than psychological interventions compared with younger adults. There is a recognized need to increase access to early, psychological intervention and preventative mental healthcare for older adults globally. Improving access to mental health services in rural areas is a national priority. The combined risks of an ageing population, inadequate service preparedness and comparatively poor mental health service utilisation by older adults, increases the likelihood of a large-scale mental health crisis. Mental health literacy (MHL) is associated with the recognition of mental health needs, service utilisation and improved mental health outcomes. Psychoeducation is often an integral part of low-intensity psychological intervention and receiving it is arguably linked to mental health literacy. Older adults have been found to have lower MHL and are more likely to use avoidance based coping strategies than younger adults. Little is known about the factors within older adults that perpetuate, ameliorate or confound these associations, particularly in a rural context. Objectives: A systematic review ‘The Effectiveness of Low-intensity Psychological Interventions on the Well-being of Older Adults’ synthesised the evidence for effectiveness and acceptability of low-intensity psychological interventions (self-help, psychoeducation, bibliotherapy, internet cognitive-behavioural therapy: iCBT) for older adults with mild-to-moderate mental health problems. A cross-sectional questionnaire-based survey ‘An Exploration into the Relationships between Mental Health Literacy, Experiential Avoidance and Mental Health in Older Adults in a Rural Scottish Region’ was used to explore the level of MHL, and the relationships between MHL, mental health, experiential avoidance, willingness to use mental health services and demographic variables in community-dwelling older adults in a rural Scottish region. Methods: The systematic review protocol was registered on Prospero prior to data extraction. Ovid, EBSCOhost and ProQuest were searched for articles describing low-intensity psychological interventions. Pre and post outcome measures and a mean age of at least 50 (age range ≥40) were required for inclusion. One hundred and fifty two respondents (aged ≥65, M = 71.9) took part in the questionnaire study. The MHL Scale, Acceptance in Action Questionnaire-II (experiential avoidance) and Clinical Outcomes in Routine Evaluation-10 (mental health status) measured the variables of interest. Results: The 26 articles describing 23 studies included in the systematic review described (guided) iCBT, bibliotherapy, self-help, psychoeducation and audio interventions. The majority of studies were of good quality and reported improvements in participant’s mental health scores post intervention. Participants were more likely to be female, aged 60-70 and to have obtained further education. Eight studies reported obtaining participant satisfaction ratings. Three studies reported collecting data from both rural and urban areas. The empirical study found that respondents had good MHL. Half of the respondents reported being aware of local mental health services for older adults. Older age (r (146) = -.32, p < .001) and lower educational attainment (F (1,145) = 5.34, p = .020) were associated with poorer MHL in our sample. MHL was not significantly correlated with mental health problem severity or experiential avoidance. Self-reported willingness to use mental health services was associated with lower experiential avoidance (ρ (146) = -.266, p = .001), better mental health (ρ (146) = -.193, p = .018) and better MHL (ρ (146) = .467, p ≤ .001). However, the single-item measure of willingness to use mental health services was unreliable due to its significant negative skew and narrow range of data points. Those who had used mental health services had higher MHL, higher experiential avoidance and poorer mental health than those who had not. Conclusions: The findings from the systematic review provide tentative evidence to support the use of guided, low-intensity psychological interventions for mild-to-moderate mental health problems in older adults. Guided iCBT and bibliotherapy may be beneficial for older adults in their 60s and 70s experiencing mild-to-moderate levels of depression. iCBT may also be beneficial for reducing symptoms of mild-to-moderate anxiety. Providing the option of low-intensity psychological intervention, particularly iCBT, may help to increase participant engagement with treatment. Given difficulties in mental health service accessibility (both face-to-face and online) for those living in rural areas, future research should strive to specify whether participants are from rural or urban areas and explore any differences in outcomes. Improving rural-dwelling, older adults’ MHL and their awareness of locally available services and supports may help to increase their willingness to seek mental health support.