Introduction

The population of older adults is steadily increasing, and this is a major challenge for the health systems globally. Old age is associated with certain age-related neuropsychiatric disorders, such as dementia, and older adults are susceptible to other mental disorders as well. Yet, even common mental disorders, such as depression may remain unrecognized in this population and once diagnosed, only a minority of patients receive adequate treatment.1 Moreover, the delivery of mental health care for older patients may be challenging. Old people may delay or even fail to contact mental health services for several reasons associated with age, such as cognitive decline and physical morbidity,2 and this may be even more relevant for those living in rural and remote areas, which mostly lack adequate mental health services.

Mental Health Care Delivery for Older Adults by Specialized Services

To address the mental health needs of the vulnerable population of older adults, several Western countries have launched specialized mental health services for those patients. A previous systematic review suggested that home-based mental health treatment for older adults is effective in improving psychopathology.3 In the state of Victoria, Australia, aged persons’ mental health services have evolved over the past decades to well-structured and organized system of services across both metropolitan and rural regions.4 Recently, Reifler and Bruce5 presented 10 long-standing and successful programs that provided home-based services to mentally ill older adults in the United States. Moreover, in the United Kingdom, where the implementation of community mental health teams (CMHTs) has become the cornerstone of mental health services for older people, research has been undertaken to elucidate the factors that would improve feasibility and effectiveness.6 In addition, a framework for an evidence-based model of CMHTs for older people has been provided, which favored domiciliary assessment and team working involving health and social care staff.7

Several challenges in providing mental health care for older adults have been recorded. Futeran and Drapen8 studied 97 older adults who received treatment by specialized services and found that the majority of social needs of the patients were unmet. Cummings9 proposed that enhanced training of mental health professionals is essential so that adequate services may be provided to the vulnerable population of older adults. However, financial resources5 and staffing10 have been recognized as challenges affecting feasibility of specialized mental health care for older adults.

Rural Areas’ Perspective

It is widely recognized that rural and remote areas do not receive adequate mental health care due to socioeconomic and geographical reasons, and distant facilities.11 Moreover, it has been suggested that even moderate distance may reduce the utilization of community-based mental health services.12 Other challenges in providing efficient mental health services in rural areas, such as difficulties in recruiting, retaining, and developing a trained workforce have been also recorded.13

It is also possible that the lack of specialized services in rural areas affects patients’ outcomes, as supported by the literature on other medical conditions. For instance, a recent study in the United States reported that patients who sustain traumatic brain injury in rural, predominantly low-resource environments have a significantly higher risk of poor outcome (i.e., death) than those in urban, high-resource environments.14 All these notions may be even more relevant in older rural residents.

The Current State of Research on Mental Health Needs of Older Adults in Greece

Research on mental health in older adults in Greece is scarce, with the exception of dementia.15 16 17 Some of the few epidemiologic studies have yielded worrying results. In a large international survey in 13,498 older people from nine European countries, it was found that residents in Italy, Greece, and Spain have the worst mental health, that is, high rates of depressive symptoms and low rates of well-being.18 This study presented data from 2004 that is before the emerge of the economic crisis which largely affected Greece and has been associated with increased prevalence of several common mental disorders.19 20 Other recent research on older adults in Greece revealed high rates of depressive symptoms21 and this is also the case of older rural residents.22 Importantly, research suggested that there is a remarkable underdetection of depressive symptoms in older adults in Greece.21 Most recently, a study in Crete, Southern Greece, found that there was an increase in suicide rates in middle-aged and elderly men between 1999 and 2013. Most importantly, suicide mortality rates have decreased in Western Crete and increased in Eastern Crete, an area where the network of community mental health services is markedly underdeveloped.23

Despite the reported needs, preventive interventions for mental health of the elderly have not been adequately developed in the context of psychiatric reform in Greece,24 and serious deficiencies in the provision of care for old people has been recorded.25 In fact, only a few efforts have been made to address those needs. Those initiations mostly involve the development of specialized outpatient services for patients with dementia26 and a few outpatient services for the elderly as part of the psychiatric departments in some general hospitals. All these services have been developed in urban settings. The problem is even more intense in rural and remote areas, the population of which do not receive adequate mental health care due to lack of services or distant facilities.27 Importantly, older adults comprise a large proportion of the population in those areas.28 Conceivably, mental health care delivery for older adults in rural areas of Greece is particularly challenging.

The Case of Mental Health Services in Rural Areas in Greece

Health care delivery in rural Greece is mostly based on primary health care,29 and older adults are frequently examined for medical problems and been prescribed medications by primary care physicians. However, there is ample evidence that primary care physicians have difficulties in diagnosing and treating mental disorders. Primary health care physicians may often not diagnose and address properly even common mental disorders such as depression,30 31 and this is probably the case of psychogeriatric syndromes as well.

To address the rural areas’ mental health needs, the Greek state has launched several multidisciplinary teams, the so-called mobile mental health units (MMHUs) over the past decades. MMHUs are low-cost services because they deliver generic mental health services and they use the infrastructures and resources of the well-established primary health care system in those areas.32 33 Those MMHUs are mostly focus on patients with severe and chronic mental disorders, such as psychotic disorders, but in fact, they treat all referred patients, regardless of diagnosis, since they are the only mental health services in those areas.

Implications for Mental Health Care

It has been suggested that the psychiatric reform in Greece is still incomplete, and several specialized services, including geriatric mental health services are underdeveloped. The situation is further complicated by the impact of the financial crisis that has led to increased demand for services, funding difficulties, and staff shortages.34 Taking into account the economic restrictions and budget cuts for mental health, the development of specialized services for older adults in rural areas in Greece seems unlikely at present. Currently, the specialization in geriatric psychiatry is not developed in Greece, but even if there were adequate number of trained workforce, working in rural areas has several adversities for health professionals13 and may not be attractive, and this would raise obstacles in staffing of rural mental health services.

The delivery of mental health services for older adults living in those areas can be pursued through the existing services that are the MMHUs. Those MMHUs regularly examine and treat older rural residents, and there is some evidence that they may trace and treat homebound older adults through domiciliary visits, who would otherwise remain undiagnosed and untreated.35 36 For the delivery of effective services to older adults, MMHUs should incorporate principles and skills of psychogeriatric care in regular clinical practice. This could be achievable through further training of their personnel in psychogeriatrics and training in general medical conditions as those are commonly encountered in the elderly in routine clinical practice.37

The importance of the contribution of primary health care physicians in the detection and management of mental disorders in older adults should be also highlighted. Primary care physicians in rural areas regularly examine and treat elderly patients, but mental disorders are often undetected in primary care settings.30 31 The phenomenon is accounted for by several reasons, including reluctance of primary health care physicians to work with people with mental disorders, reduced time availability, and inadequate supervision of primary care staff by mental health professionals.38 Caring for all psychiatric syndromes in the elderly is particularly demanding for primary care physicians and is an unfeasible goal, but at least they could be aware of the nontypical clinical presentation of various psychiatric syndromes in the elderly and properly arrange referral to specialized mental health services that are the MMHUs. This could be attained through appropriate training and support. For instance, the Australian government has implemented the Rural Clinical School Program, for the support of the rural health work-force.39 In Greece, there have been several initiations for primary care physicians’ training in mental health, and it has been suggested that after intensive education programs, they may become efficient in early diagnosis and effective management of mental disorders.40

It has been reported that primary care physicians’ training in mental health per se may not be sufficient for the improvement of outcome in patients with common mental disorders.41 The need for access to psychotherapeutic and psychiatric expertise and collaboration with psychologists and psychiatrists has been recognized,42 yet several difficulties in communication between primary care and mental health care services and in referrals have been described in the literature.43 However, in the case of MMHUs in rural Greece, these barriers are less relevant. MMHUs are locally based and have been integrated successfully within the primary care system, thus facilitating referrals and cooperation.44

Conclusion

Mental health care delivery for older adults in rural areas in Greece is still challenging, in an era of economic crisis and limited resources. Till the introduction of specialized teams, the best chance of providing quality mental health services for older adults in rural Greece is to invest on the preexisting services that are the MMHUs. The workforce of those multidisciplinary units should be additionally trained in psycho-geriatric care. The enhancement of the co-operation among primary care and mental health professionals could provide a unique opportunity for on-site training of the former in psychiatric and psychogeriatric issues. This would facilitate appropriate treatment of mental disorders by primary care physicians and timely referral to the MMHUs when needed.