BACP Written Submission to the Health, Social Care and Sport Committee Inquiry into Loneliness and Isolation
1. Introduction
The British Association for Counselling and Psychotherapy (BACP) welcomes the opportunity to contribute to this important inquiry. Loneliness and isolation has significant impact on physical and mental health and is a leading cause of anxiety and depression, as well as increased suicide rates, particularly for older people. Loneliness reduces life expectancy, increases the risk of premature death by a quarter[1] and is said to have an effect on mortality that is similar to smoking 15 cigarettes a day[2].
More than 75% of women and a third of men over the age of 65 live alone. Without the means to leave their homes, or with fewer visits from community workers and service providers, an increasing number of older people will feel lonely and isolated resulting in damaging effects to their mental health[3]. Age Cymru’s 2014 omnibus survey further highlights the scale of the challenge in Wales, where over 75,000 older people “always or often” feel lonely, and 14% of respondents reported feeling “cut off from society”[4].
BACP are the leading professional body for counselling and psychotherapy in the UK, with over 44,000 members, and 1,800 members in Wales. Our practitioner-members are based in a range of settings in Wales, including the NHS and third sector, providing therapy to clients with a wide range of presenting issues. BACP recognises the critical role that counselling and psychotherapy can play in helping to manage the adverse mental health effects of loneliness and isolation and our written evidence focusses on this important aspect of the inquiry.
2. The link between loneliness and isolation and depression
2.1. The link between loneliness and isolation and depression is well evidenced and documented. Loneliness has been found to increase the symptoms of depression beyond what can be explained by initial levels of depressive symptomatology[5]. Whilst loneliness predicts changes in depressive symptoms, depressive symptoms do not predict changes in loneliness. Loneliness remains the significant predictor of changes in depressive symptomatology[6] . Loneliness has also been found to be a significant predictor of anxiety[7].
2.2. There is a clear correlation between old age, isolation and depression. People over 65, particularly older women, are more prone to depression than any other age group in Wales.[8] Depression affects around 22% of men and 28% of women aged 65 years and over[9].
2.3. However, despite the high numbers suffering it is estimated that 85% of older people with depression receive no help at all from the NHS and remain undiagnosed and untreated[10]. Furthermore, untreated depression is the leading cause of suicide amongst older people, with men living alone at particularly high risk[11].
2.4. Whilst we understand the inquiry’s focus on older people, it is important to also highlight the other vulnerable groups who are at risk of isolation, such as teenagers and young unemployed adults, recently retired people, new mothers, immigrants and people with physical disabilities and learning disabilities. We also reflect their needs in our recommendations.
3. The role of psychological therapies in tackling depression
3.1. In line with the findings of Hill and Brettle (2004; 2005), counselling and psychotherapy are effective interventions for people experiencing psychological distress, particularly for anxiety and depression. The outcomes for older people are equivalent to that of younger populations.
3.2. The most recent IAPT report in England found that outcomes for Older People who access psychological therapies are good, with recovery rates of approximately 60% in the over 65’s, compared with under 50% in the general adult population. Within this outcomes for a range of psychological therapies were found to be comparable, including cognitive behavioural therapy (CBT), counselling for depression (CfD), and interpersonal psychotherapy (IPT).
3.3. Whilst not covered by the remit of the inquiry we urge the Committee to also consider the role and impact on carers of older people. In Wales, 370,230 people provide unpaid care, some 12% of the population. Census data found that carers in Wales who are providing high levels of care were three times more likely to suffer ill health than non-carers.[12]
4. Barriers to accessing psychological therapies for older people
4.1. Whilst older people consult their GP almost twice as often as other age groups, only one in six older people with depression discuss their symptoms with a GP[13] and only 15% receive the specialist mental health care they need.[14] There are a number of reasons for this.
4.2. Older people may present with non-specific symptoms such as malaise, tiredness or insomnia rather than disclosing depressive symptoms. In addition, physical symptoms, including pain, are common and the primary care clinician may feel these indicate organic disease. Older people sometimes have beliefs that prevent them from seeking help for depression, such as a fear of stigma or that antidepressant medication is addictive[15].
4.3. Older people from black and minority ethnic backgrounds often do not see mental health services as appropriate. People from different ethnic groups may present with culturally specific idioms of distress. This may lead practitioners to overlook psychological distress and focus solely on the physical aspects of the presentation[16].
4.4. Primary care practitioners may lack the necessary consultation skills or confidence, to correctly diagnose later life depression, or may see the symptoms as part of the ageing process[17]. GPs often feel unsupported due to the lack of availability of psychological interventions and or a lack of knowledge of associated services in their local areas.[18]
5. Government Support to tackle Loneliness and Isolation
5.1. BACP is supportive of the commitment that the Welsh Government made to secure the mental health and wellbeing of all of its people, as signalled in the Well-being of Future Generations (Wales) Act 2015 and through the publication of Taking Wales Forward[19], which includes an important commitment to “Help people live healthy and independent lives” with a big focus on building resilience for the whole population while also supporting those with the greatest health need and poorest health outcomes.
5.2. This commitment is further exemplified through the Ageing Well Wales Programme (2014-19), which fully recognises the grave physical and mental health impacts of loneliness and isolation and highlights this as a priority area for intervention. Beneath this flagship national policy, Local Ageing Well Plans have been produced by every Local Authority in Wales. Whilst we support the will of local areas to design services they need, the quality and status of plans is diverse. Whilst most clearly highlight the need to tackle mental health challenges associated with loneliness and isolation, only a small number of these focus on tackling depression by ensuring older people get access to appropriate therapies. We would particularly like to highlight Bridgend and Merthyr Tydfil as well developed examples.
5.3. BACP is also supportive of the Welsh Government’s flagship Mental Health Action Plan - Together for Mental Health, and its identification of loneliness and isolation as critical areas for Government intervention. We are supportive of the measures proposed under priority 5.2 and in particular, we welcome the proposal for a national/cross departmental approach to reduce loneliness and isolation among those at risk of mental health problems. We look forward to supporting the development of the proposed cross-government Loneliness and Isolation Strategy, recently announced by the Minister for Social Services and Public Health.
5.4. Alongside the above policies, which broadly focus on reducing physical exclusion, we would have liked to have seen greater emphasis on talking about the barriers that people face, particularly many older people, to secure adequate treatment for the mental health symptoms of loneliness and isolation. We have provided a small number of recommendations, in Section 6, which aim to address these challenges.
6. Recommendations
6.1. BACP proposes the following recommendations to inform an improved approach to managing the challenges highlighted in our evidence as well as the development of the Welsh Government’s awaited Loneliness and Isolation Strategy.
6.2. Our evidence demonstrates that psychological therapies have a key role to play in tackling the negative mental health impacts of loneliness and isolation. However, it simply isn’t good enough that 85% of older people with depression in the UK receive no access to the support they need to live with dignity. We call on the Welsh Government to show real leadership in ensuring that older people in Wales get better support and access to appropriate talking therapies.
6.3. We are pleased to see that the stigma toward mental health is improving in Wales, as evidenced by the 2017 Time to Change Survey, where 4.7% more people indicated a positive attitude to Mental Health over the past five years[20]. However, stigma remains a significant barrier for many older people and people from BME communities to get the support they need. We call on Welsh Government to do more to improve awareness with vulnerable groups and communities and we believe this should be at the heart of the new Loneliness and Isolation Strategy.
6.4. Public Health Wales NHS Trust, has a key role to play through its Healthy and Well Communities Programme, to support community and third sector organisations to develop collaboration approaches to tackling loneliness and isolation. Alongside this we would like to see a commitment to ensure local Health Boards are providing adequate access to psychological therapies, as well as ensuring appropriate links are being made to Local Ageing Well Plans to ensure a joined up approach.
6.5. Whilst we welcome the development of Local Ageing Well Plans that meet the specific needs of local communities, the quality and status of these is mixed and only a very small number provide adequate provision to tackle the serious mental health challenges associated with loneliness and isolation. We believe the Department has a key role to play in ensuring best practice is spread across each Local Authority to ensure older people get access to appropriate therapies and support to their mental health needs across the length and breadth of the Country.
6.6. There needs to be a greater understanding of the impact of loneliness on mental health within GP and social services, together with better awareness of the positive impact of psychological therapies – ensuring that mental health assessments take better account of the impact of loneliness, and that people are directed to receive the appropriate support they need.
6.7. Healthcare providers and commissioners in Wales need to focus on developing services which support all those groups at greater risk of social isolation, such as teenagers and young unemployed adults, recently retired people, immigrants and people with physical disabilities and learning disabilities, so that individuals can be offered support at an early stage, reducing the chance of their developing chronic loneliness with all its ensuing and costly physical and mental health problems.
7. Contact Details
Martin Bell, Deputy Head of Policy and Public Affairs
British Association for Counselling and Psychotherapy.
BACP House
15 St John's Business Park, Lutterworth LE17 4HB Contact us
Email: publicaffairs@bacp.co.uk
____________________________________________________________________________________
Annex A
Detailed References (A-Z)
· Age Cymru and Age UK, TNS Omnibus survey, April 2014
· Age UK, No one should have no one, December 2016
· Age Concern and Mental Health Foundation, Promoting mental health and well-being in later life: a first report from the UK Inquiry into Mental Health and Well-Being in Later Life., 2006
· Audit Commission in Wales. (2004). Developing Mental Health Services for Older People in Wales.
· Burroughs H, Morley M, Lovell K et al (2006). ‘Justifiable depression’: how health professionals and patients view late-life depression – a qualitative study. Family Practice 23: 369–377.
· Cacioppo, J. T., Hawkley, L. C., and Thisted, R. A. (2010). Perceived Social Isolation Makes Me Sad: 5-Year Cross-Lagged Analyses of Loneliness and Depressive Symptomatology in the Chicago Health, Aging, and Social Relations Study, Psychology and Aging, 25(2):453–463
· Cacioppo, J. T., Hughes, M. E., Waite, L. J., Hawkley, L. C., & Thisted, R. A. (2006). Loneliness as a specific risk factor for depressive symptoms: Crosssectional and longitudinal analyses. Psychology and Aging, 21, 140–151.
· Green, B. H., Copeland, J. R., Dewey, M. E., Sharma, V., Saunders, P. A., Davidson, I. A. & McWilliam, C. (1992). Risk factors for depression in elderly people: A prospective study. Acta Psychiatrica Scandinavica, 86, 213–217.
· Hagerty, B. M., & Williams, A. R. (1999). The effects of sense of belonging, social support, conflict, and loneliness on depression. Nursing Research, 48, 215–219.
· Health & Social Care Information Centre. (2007). Health Survey for England, 2005: Health of Older People.
· Heikkinen, R.-L., & Kauppinen, M. (2004). Depressive symptoms in late life: A 10-year follow-up. Archives of Gerontology and Geriatrics, 38(3), 239–250.
· Muyan, M., Chang, E. C., Jilani, Z., Yu, T., Lin, J and Hirsch, J. K. (2015). Loneliness and Negative Affective Conditions in Adults: Is There Any Room for Hope in Predicting Anxiety and Depressive Symptoms? The Journal of Psychology, 150:331 – 341
· NHS Digital (2016). Psychological Therapies: Annual report on the use of IAPT services England, 20116
· Older People’s Commissioner for Wales, The Importance and Impact of Community Services within Wales, February 2014
· Office for National Statistics. (2013). 2011 Census Analysis: Unpaid care in England and Wales, 2011
· Primary Care Mental Health Forum, Management of Depression in Older People, 2014
· Rabins P (1996). Barriers to diagnosis and treatment of depression in elderly patients. American Journal of Geriatric Psychiatry 4: 79–84.
· Smyth, C. (2014). Depression in old age ‘is the next big health crisis’. Retrieved from: http://www.thetimes.co.uk/tto/health/news/article40572
· Time to Change Wales, State of Stigma Statistics in Wales, February 2017
· Wei, M., Russell, D. W., & Zakalik, R. A. (2005). Adult attachment, social self-efficacy, self-disclosure, loneliness, and subsequent depression for freshman college students: A longitudinal study. Journal of Counseling Psychology, 52, 602–614.
· Weeks, D. G., Michela, J. L., Peplau, L. A., & Bragg, M. E. (1980). Relation between loneliness and depression: A structural equation analysis. Journal of Personality and Social Psychology, 39
· Welsh Government, Taking Wales Forward, November 2016
· Welsh Government. (2011). Carers Strategies (Wales) Measure 2010: Guidance issued to Local Health Boards and Local Authorities.
[1] Age UK, No one should have no one, December 2016
[2] Welsh Government, Ageing Well Wales, 2014-19
[3] Older People’s Commissioner for Wales, The Importance and Impact of Community Services within Wales, February 2014
[4] Age Cymru and Age UK, TNS Omnibus survey, April 2014
[5] (Cacioppo, Hughes, et al., 2006; Green et al., 1992; Hagerty & Williams, 1999; Heikkinen & Kauppinen, 2004; Wei, Russell, & Zakalik, 2005; cf. Weeks et al., 1980. Full details in Annex A
[6] Cacioppo, J. T., Hawkley, L. C., and Thisted, R. A. (2010). Perceived Social Isolation Makes Me Sad: 5-Year Cross-Lagged Analyses of Loneliness and Depressive Symptomatology in the Chicago Health, Aging, and Social Relations Study, Psychology and Aging, 25(2):453–463
[7] Muyan, M., Chang, E. C., Jilani, Z., Yu, T., Lin, J and Hirsch, J. K. (2015). Loneliness and Negative Affective Conditions in Adults: The Journal of Psychology, 150:331 – 341
[8] Audit Commission in Wales. (2004). Developing Mental Health Services for Older People in
Wales. Retrieved from http://www.wales.nhs.uk/documents/MHSOP-20report.pdf
[9] Health and Social Care Information Centre. (2007). Health Survey for England, 2005: Health of Older People. Retrieved from http://www.hscic.gov.uk/pubs/hse05olderpeople
[10] Smyth, C. (2014). Depression in old age ‘is the next big health crisis’. Retrieved from: http://www.
thetimes.co.uk/tto/health/news/article40572
[11] Primary Care Mental Health Forum, Management of Depression in Older People, June 2014
[12] Welsh Government. (2011). Carers Strategies (Wales) Measure 2010: Guidance issued to
Local Health Boards and Local Authorities.
[13] Age Concern, Promoting mental health and well-being in later life: a first report from the UK Inquiry into Mental Health and Well-Being in Later Life. London: Age Concern/Mental Health Foundation, 2006
[14] Smyth, C. (2014). Depression in old age ‘is the next big health crisis’. Retrieved from: http://www.
thetimes.co.uk/tto/health/news/article40572
[15] Primary Care Mental Health Forum, Management of Depression in Older People, June 2014
[16] Primary Care Mental Health Forum, Management of Depression in Older People, June 2014
[17] Rabins P (1996). Barriers to diagnosis and treatment of depression in elderly patients. American Journal of Geriatric Psychiatry 4: 79–84.
[18] Burroughs H, Morley M, Lovell K et al (2006). ‘Justifiable depression’: how health professionals and patients view late-life depression – a qualitative study. Family Practice 23: 369–377.
[19] Welsh Government, Taking Wales Forward, November 2016
[20] Time to Change Wales, State of Stigma Statistics in Wales, February 2017