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Old doesn't equal crazy

It's a bad marriage of two prejudices, ageism and crazyism. Working together, they are doubly vicious, throwing up medical barriers against people of a certain age who suffer a mental illness.

The results are predictable. The majority of these people don't get the care they need. The treatment they do get is often substandard. They tend not to get the latest, most effective medications. They are rarely offered psychotherapy or even properly evaluated for a mental disorder. And they have the highest suicide rate of any age group _ victims of an act of violence that is largely due to untreated or mistreated depression.

Leaders in mental health and aging gathered in Washington in November to design ways to reduce the dual stigma faced by millions of Americans who are seen as both "over the hill" and "loony." The stereotype worms its way into public perception: Aunt Ethel has macular degeneration _ no wonder she's depressed. Poor old Dad _ just didn't want to live after the heart attack. And the homeless man on the corner mumbling to himself _ crazy old coot.

This is prejudice. It's fueled by the myth that going mad is a normal part of growing old. It is reinforced by the stereotype that older people are too set in their ways to respond to treatment. (You can't teach an old dog new tricks.)

The surgeon general has warned that this dual prejudice is hazardous to health. There are some unique aspects for older adults. They suffer more chronic medical conditions and suffer more loss of relationships. "It's easy for the informed physician or family member to say, "If I had all these problems, I would want to die,' " said psychiatrist Stephen J. Bartels of Dartmouth-Hitchcock Medical Center in Lebanon, N.H. The individual internalizes that message, too. "All these things come together so that older adults get less access to mental health care than any other age group."

Depression in older people is not a normal response to having a heart attack, breaking a hip or getting diagnosed with cancer. It needs to be treated in addition to the other medical conditions.

Depression is not a normal part of grief. Feeling sad over losses _ the death of loved ones, the loss of function or status _ is part of grieving and moving on. But incapacitation by hopelessness for months on end needs to be treated, just as diabetes or leukemia needs to be treated.

The stigma roundtable, sponsored by the federal Center for Mental Health Services, sought to spread a message of hope. The strongest voices came from those who have recovered from mental illness and enjoy meaningful lives.

Sometimes a mental disorder does not emerge until late in life. George Kotwitz, 66, of Yukon, Okla., had his first episode of depression when he was about 50. It was triggered by a catastrophic financial reversal. He had built up a successful fire and casualty insurance business, and after he sold it the deal went sour. "I lost everything. I lost my house. I went into bankruptcy," he said. "I lost the ability to read and tell you what I was reading. I lost the ability to function. I lost all confidence."

The break came at a family party. "I started screaming" and ran outside, he recalled. "I realized I had gone crazy." His wife came after him and got him to a hospital.

On the long road to health, he's been hospitalized nine times. "I finally realized I had a major part in my recovery," he said. "I became more assertive. I would tell the doctor, "I don't like these side effects. I'm not going to stand for it.' "

He tried more than 15 drugs before finding two that worked for him. "It's wonderful. I started setting goals for myself. I started associating with people." Now he's working again, looking after his wife of 43 years, helping others with mental illness. "Find a reason for hope," he said. "Quality of life becomes mental wellness."

In other instances, people have lived with a chronic mental disorder _ and other prejudices _ for years. Sometimes there is a mellowing out of the disease. Janet Stiles, 72, of Manchester, N.H., had her first episode at age 28, after having three children. "One morning I couldn't get out of bed," she recalled. The doctor diagnosed "hysteria." "I was furious," she said of this first encounter with crazyism and sexism. She was eventually diagnosed with schizophrenia and treated with medication. She stopped taking drugs almost 20 years ago and continued treatment with cognitive therapy. Meanwhile, she got involved in the community, took up swimming and then went to work. Since retirement, she and her husband have kept busy and enjoy their five grandchildren.

Hikmah Gardiner, 74, of Philadelphia works for the Mental Health Association of Southeastern Pennsylvania. In the beginning, she had to fight the dual stigmas of crazyism and racism. When she was in her 20s, she was misdiagnosed as having schizophrenia _ because the doctor said that's what African-Americans get when they get a mental illness, she recalled. She self-medicated with alcohol. "Then I had two problems," she said. She became homeless. One day, a friend took her to a doctor. She attended AA meetings. She found a good psychologist. That was 40 years ago.

What gives her pleasure today?

She finds fulfillment in her work and her great-grandsons. "The difference between a saint and a sinner is the saint keeps trying," she said.

These voices of hope chip away at the stigma wall, brick by brick. But it will take a massive change in the health-care community to tear it down.