Beyond silence: Addressing mental health challenges and hopeful pathways for older adults

Abstract

In this editorial, I comment on the article conducted by Yang and Woo. Mental health in older adults remains underserved and underexamined, with final decades shaped by cumulative life stressors, chronic conditions, and social determinants that disproportionately affect marginalized communities. In this study, I would like to synthesize current evidence on the prevalence, presentation, and trajectories of mental health concerns among older adults, highlighting common challenges such as late-life depression, anxiety, cognitive concerns, and underutilization of care. I am going to examine barriers to outreach and treatment, including stigma, cultural and linguistic mismatches, access limitations, and gaps in geriatric mental health services. The analysis in the paper identifies promising pathways to improve outcomes: Community-engaged interventions, culturally tailored care models, integration of mental health with primary and geriatric care, and policy reforms to expand coverage and reduce disparities. As a conclusion, with actionable recommendations for clinicians, researchers, policymakers, and community organizations to break the silence, enhance early detection, and foster resilient aging through equitable, person-centered approaches.

Key Words: Mental health; Older adults; Challenge; Stigma; Pathways

Core Tip: The current understanding of geriatric mental health recognizes well-being as the outcome of multiple intersecting social determinants economic, cultural, familial, and systemic factors rather than a single cause. Recognizing the lived experiences of marginalized groups, such as Asian American older adults, draws attention to disparities in prevalence, symptomatology, and access to mental health care. Focusing on stigma, language barriers, and health literacy highlights tangible obstacles to seeking help and adhering to care, which are frequently underemphasized in clinical conversations.

INTRODUCTION

In a small coastal town, 78-year-old Rosa spent her days crocheting on the porch, feeling increasingly isolated after her husband passed away. When the community center introduced a bilingual senior program focusing on mental health and social connection, Rosa joined a weekly circle. Within months, she reported more energy, improved sleep, and a renewed sense of purpose, reminding everyone that aging well often starts with belonging and support[1].

As this case illustrates, among adults aged 65 and older in the United States, racial and ethnic minority groups experience higher rates of unmet mental health needs than non-Hispanic whites. Approximately 25% of Hispanic older adults with a mental health condition did not receive any treatment in recent years, compared with roughly 15% of their non-Hispanic white peers. This gap persists even when controlling for income and insurance access, highlighting the role of stigma, cultural relevance, and systemic barriers in shaping disparities in care.

Evidence that mental health in older adults is shaped by economic, cultural, familial, and systemic factors is consistent with current literature[2,3]. Mental health interacts with these determinants to influence risk, resilience, access, and outcomes. Financial security, retirement resources, housing stability, and access to affordable care critically affect both the prevalence of conditions (e.g., depression, anxiety) and the utilization of services. Economic stress can exacerbate chronic illness management and reduce social participation, which in turn impacts mental well-being of individuals aged 65 and older[4,5]. Furthermore, cultural beliefs about aging, stigma surrounding mental illness, language proficiency, and health literacy shape help-seeking behavior and treatment adherence. Culturally relevant and humble approaches to care delivery improve engagement and outcomes for elders[3]. Family dynamics, caregiving burdens, intergenerational transmission of coping styles, and social networks may serve either as buffers or as stressors. Strong family support can mitigate loneliness and isolation, whereas caregiver strain can worsen mental health for both older adults and caregivers.

Addressing stigma is essential, as stigma can delay or prevent help-seeking, reduce the perceived legitimacy of mental health concerns, and reinforce disparities[6]. Anti-stigma strategies should be culturally tailored and community-informed. These strategies should be accompanied by accessible and trusted care pathways[3]. Strengthening social networks and community engagement (e.g., senior centers, faith-based groups, peer support programs) can enhance detection, reduce isolation, and improve treatment adherence. Social connectedness often buffers against adverse outcomes even when economic or systemic barriers persist.

THE SCALE OF THE ISSUE: PREVALENCE, IMPACT, AND RACIAL AND CULTURAL DISPARITIES

Prevalence of mental health challenges in older adults

Depression, anxiety, and cognitive health issues are common among older adults, but prevalence and presentation vary markedly by setting[7]. Distinguishing between community-dwelling and long-term care (LTC) populations is crucial for accurate interpretation, screening, and intervention planning. Rates of clinically significant depressive symptoms typically range from about 5% to 15%, depending on measurement tools, cutoffs, and populations studied. Subclinical symptoms and chronic medical comorbidities further elevate risk, while social isolation and functional decline are important contributors[7]. Depression prevalence is often higher in LTC settings, frequently reported in the range of 15% to 40%, reflecting greater functional impairment, loss of autonomy, bereavement, pain, and adjustment to LTC environments[8].

Anxiety commonly co-occurs with medical conditions and insomnia, and its somatic manifestations may be mistaken for physical illness[9]. Environmental stressors, such as transition to communal living, loss of privacy, or unfamiliar routines, can heighten situational anxiety among adults aged 65 and older. Dementia is another major mental health challenge for older people, and its prevalence varies by population but generally ranges from 5% to 8% in those aged 65 and older, with rates increasing with age. Alzheimer’s disease is the most common etiology[10]. Early detection and routine cognitive screening facilitate planning and care coordination. Chronic illnesses, pain, sleep disturbances, and functional dependence can elevate depressive and anxiety symptoms and may mimic or mask cognitive decline. LTC environments may inadvertently contribute to mood and cognitive concerns through social isolation, limited autonomy, and staff-patient ratios. By contrast, community settings provide more opportunities for social engagement but may present gaps in access to care[10]. Underreporting of mood symptoms is common in all settings due to stigma, fear of labeling, or lack of mental health literacy. Proactive screening and destigmatizing care approaches are therefore essential. In addition, staff training and care planning influence detection and management, while in community settings, primary care providers and geriatric psychiatrists play pivotal roles in identifying and treating mood and cognitive disorders.

Another concern among adults aged 65 and older is alcohol and prescription drug misuse[11]. Although overall prevalence is lower than in younger populations, problematic use affects between 5% and 15% depending on definitions and settings. Late-life stress, grief, bereavement, isolation, and social withdrawal are also highly prevalent and can exacerbate depressive and anxiety symptoms[12]. Sleep disorders, particularly insomnia, are likewise common and strongly linked to mood disturbances and cognitive impairment.

Impact of mental health challenges

Mental health challenges in older adults have wide-ranging consequences, including functional and cognitive decline, comorbidities, diminished quality of life, and impaired social well-being.

Depression and anxiety are associated with slower physical recovery, worsened functional status, higher disability, and greater dependence on caregiving[13]. Mental health problems can also exacerbate chronic diseases (e.g., cardiovascular disease, diabetes) and complicate treatment adherence. Depression is further linked to increased hospitalization, longer hospital stays, higher mortality risk among older adults with medical illnesses, and in some cases, accelerated cognitive decline. Mental health issues reduce life satisfaction, social participation, and perceived quality of life[14]. Social isolation, loneliness, and bereavement amplify these risks and worsen outcomes.

Racial and cultural disparities

Prevalence estimates may differ by race/ethnicity due to cultural expressions of distress, stigma, help-seeking behaviors, and disparities in access to care. Minoritized older adults often experience underdiagnosis or misdiagnosis, partly due to lexical and cultural differences in symptom reporting as well as clinician bias[15]. Additional barriers include limited access to culturally competent mental health professionals, language obstacles, transportation difficulties, financial constraints, and fragmented care systems. Varying levels of stigma, one of the most critical issues for older adults, around mental illness and acceptance of psychological care influence willingness to seek help[16].

THE HOPEFUL PATHWAYS

“Hopeful pathways” refer to constructive, person-centered approaches that older adults can pursue to recognize mental health needs, seek appropriate help, and engage in effective treatment, despite barriers such as stigma[17]. Illness representations, such as how depressive symptoms and mental health in later life are perceived and reframed, play a central role in reaching positive outcomes. Providing clear, culturally sensitive information about where and how to access mental health care is especially important for this group. Involving family, caregivers, and community resources encourages help-seeking, reduces stigma, and enhances quality of life[18]. Seamless coordination among primary care, geriatric services, and mental health specialists also contributes substantially to maintaining older adults’ mental health.

Yang and Woo[19] highlighted perceived healthcare discrimination among older adults and its association with greater psychological distress. Their influential paper explored the effects of coronavirus disease 2019, racism, social support, cultural stigma, and self-rated health on the well-being of older adults. The authors reviewed recent studies and future research directions, noting the lack of comprehensive reviews covering findings from the past five years. They specifically addressed vulnerabilities among older Asian Americans, the rise of anti-Asian hate, and the need for culturally aligned social support strategies that respect traditional practices. Importantly, they promoted an evidence-based understanding of mental health as a means of overcoming stigma.

Perceived discrimination in healthcare settings is consistently linked with higher levels of depressive and anxiety symptoms, poorer self-rated health, and lower satisfaction with care among older adults[20]. When individuals feel disrespected, it often leads to increased skepticism about the effectiveness of treatment, potentially exacerbating distress and reducing engagement with care. Anticipated stigma or prior negative experiences may deter individuals from seeking help promptly, thereby worsening symptoms[21]. Such discrimination erodes trust in providers and healthcare systems, undermining therapeutic relationships that are essential for adherence and shared decision-making in older populations. Also, the people who experience this discrimination may increasingly distrust healthcare providers, social services, and even family or community networks. This distrust can lead to delayed care, reduced adherence to treatment, and reluctance to seek help for mental health concerns. As stated in Yang and Woo’s study[19], perceived discrimination may activate stress pathways that contribute to sleep disturbances, mood dysregulation, and cognitive strain. Historical and ongoing experiences of racism can create a generalized expectation of bias. Based on this bias, clinicians feel unsafe or dehumanizing, which compounds stress and avoidance behaviors. Furthermore, repeated negative interactions may also foster internalized beliefs of worthlessness or hopelessness, core features of depressive experiences in older adults[21]. Discrimination can also lead to social withdrawal, isolation, or reduced participation in community activities. Social isolation is a well-established risk factor for depression, cognitive decline, and poorer quality of life in later life.

Prior studies suggest several practical considerations for addressing perceived discrimination. One is systematic detection and documentation, such as implementing brief, validated screening tools for perceived discrimination and its impact on care engagement during routine visits. Encouraging open dialogue with such questions as “how did you feel about today’s visit? Do you have any concerns about bias or respect in your care?” can foster trust. Other key strategies include effective communication and relationship-building. Safe communication requires active listening, confirming understanding, validating concerns without defensiveness, and ensuring language accessibility and culturally congruent communication, with interpreters or culturally matched staff whenever possible[22]. “Ageing as illness” narratives should be avoided through respectful, non-stigmatizing language. It is also crucial to acknowledge how different cultures interpret symptoms, including somatization, spiritual frameworks, and stoicism, to promote safe, culturally sensitive communication.

CLINICAL IMPLICATIONS

This paper provides comprehensive clinical implications tailored to the current study on mental health concerns in older adults, organized to support the conclusion and actionable recommendations for clinicians, researchers, policymakers, and community organizations. Routine screening for mood, anxiety, and cognitive concerns should be offered in primary care and geriatrics clinics, with explicit attention to discrimination-related stress and social isolation. Developing and disseminating culturally tailored psychoeducation and brief interventions that address both mental health symptoms and social determinants are critical. Funding and expanding community-based programs that promote social connection, reduce stigma, and provide safe spaces for discussions of discrimination and aging are the main implications for current study.

CONCLUSION

Perceived healthcare discrimination is a meaningful correlate of mental distress among older adults and has implications for help-seeking, engagement, and outcomes. Practical actions span individual behavior, team-based care, organizational culture, and policy-level changes to reduce discrimination and support mental health. For future considerations, to investigate not just whether discrimination exists, but how specific interactions influence help-seeking and treatment adherence over time, and to address structural inequities in access to mitigate drivers of perceived discrimination and its mental health impact, are essential.

ACKNOWLEDGEMENTS

My sincere thanks go to the authors conducting this significant topic in public health and providing valuable insights.