Older people face barriers to Talking Therapies

According to Independent Age, around 75% of people aged 65+ have experienced significant anxiety or low mood. Yet older adults are also less likely to be referred to therapy; one study even found that younger adults were 80% more likely to receive therapy. This underrepresentation is also present in Talking Therapies (formerly IAPT), the NHS pathway for treatment for anxiety and depression, where older adults represent just 5.1% of referrals.

This isn't just because doctors overlook older people's mental health issues, however: some people simply choose not to up referrals. Writing in The Cognitive Behaviour Therapist, Rachel Prosser and team paint a complex picture as to why older people might not access Talking Therapies — and offer suggestions on what can be done to increase take-up.

Firstly, to get a picture of who may not be accessing services, the team looked at the anonymised data of 3,796 clients aged 65 years and over who had been referred to Talking Therapies. Some of these participants had opted in, whereas others had not. A sizeable 23.9% of this group were not seen for Talking Therapies, even though they accepted the referral, with 15.7% not opting in at all.

Results found that those who had not enrolled were significantly older, and that a much higher proportion were from racially minoritised backgrounds, were more likely to have a disability or long-term condition, or did not speak English as their first language. Those who could not receive text messages were also less likely to opt in to therapy, underlining the impact that the digital divide can have on the receipt of healthcare services.

To identify the barriers to attending therapy sessions, the next part of the study took a qualitative approach. Through thematic analysis of interviews with eight adults aged 65+ who had been referred to, but did not opt in to, Talking Therapies, four key themes emerged.

The first theme identified issues with the process of referral and opt-in itself. While some felt that communications worked well, others felt the process was "confusing and time-consuming"; one participant wasn't even aware they had been referred until they were discharged. Calls from withheld numbers and no voicemails prevented some from opting in, even though they wanted to, due to an inability to call back. Participants also reported that communications often "missed the personal touch" needed to build trust. Overall, this suggests scope for improvement in communications, and a need to reassess the accessibility of current systems so everyone can access them.

What Talking Therapies entails was also, for some, a bit of a mystery, as the second theme explored. One participant noted they didn't know what therapy really was, and that this could act as a barrier for others. "If people don't understand what it is they might just think, I don't know if that's what I want." Similarly, others shared a desire for more information about what to expect from an appointment, particularly in terms of how therapy can help older adults specifically. While younger generations might have an easy time finding such information online, one respondent said they "wouldn't even think of Googling or looking online," suggesting further issues caused by the digital divide.

Another theme was participants' beliefs and attitudes about therapy. One stated that he felt he couldn't "talk [himself] out of problems," whereas others felt the effectiveness of therapy was largely dependent on individual therapists. They shared concerns that the relative youthfulness of clinicians would act as a barrier ("how could somebody inexperienced in life start to understand or help people?"). Stigma also played a role: the sense of shame in being able to cope stopped some people from interacting with psychological services.

Finally, other elements of ageing, such as physical and cognitive changes were also deemed a barrier. Health problems often affected participants' ability to get appointments. While online and phone appointments were presented as an alternative by some, others felt these were impersonal, stressing the need for a range of options. Follow-up reminders and information being repeated were seen as useful tactics for mitigating issues caused by memory troubles, helping potential patients keep better track of their appointments, and ultimately making them more able to attend.

Though the interviews in this study provided rich data, the small sample size no doubt limited the range of issues raised. Further investigations are merited to obtain a wider, more intersectional understanding of barriers at play.

Older people's mental health is a problem with increasing relevance: according to the World Health Organisation, one in six people will be over the age of 60 by 2030. Thinking about how best to ameliorate this is therefore an urgent priority, in order to ensure that all older people are able to access services that truly suit their needs.

Read the paper in full:

Prosser, R., Dosanjh, L., Jell, G., & Churchard, A. (2024). Which older adults do not opt-in to Talking Therapies and why? The Cognitive Behaviour Therapist, 17, e16. https://doi.org/10.1017/S1754470X24000151