Multicultural Aging and Mental Health Resource Guide

In many ways, it is almost intuitive to consider that health care providers who work with older adults are focused on issues of diversity, particularly if elder status is regarded as one of several cultural differentiators. But beyond the fact that an older adult is different because of an aging distinction, other elements that characterize a diverse population require as much attention. Other important aspects of diversity include race, ethnicity, language, gender, socio-economic status, physical ability, sexual orientation, education, location of residence and religion/spirituality. The aging population served clinically, studied and researched, and managed in organizational settings (such as long-term care facilities) challenges psychologists to continually hone multicultural knowledge, skills, abilities and other characteristics (including attitudes) — “gerodiversity” competencies.

Although many are the aspects of diversity that impact health practice, it has been effectively argued that ethnicity and race will be at the forefront of multicultural concerns for the foreseeable future if for no other reason than the substantial demographic shift in the U.S. population of an increasingly multiethnic population. By 2050, Hispanics/Latinos are expected to make up 30 percent of the U.S. population, and by 2019, the Hispanic population aged 65 and older is projected to be the largest racial/ethnic “minority” group in this age cohort. Working with racial/ethnic groups such as Latinos requires knowledge of additional diversity factors such as acculturation, indigenous beliefs for healing practices, and social justice issues including discriminatory experiences. These factors along with the previously described diversity aspects can have direct influence on aging issues of caregiving, end-of-life concerns, mental health and physical illness.

This resource guide is a useful tool for maintaining one's awareness of multicultural health issues in the aging population, and the readings can inspire the integration of multicultural knowledge in the day-to-day work of health care practice with older adults. By becoming familiar with and utilizing the educational resources described in this guide, psychologists can stay abreast of the evolving field of gerodiversity.

Yvette N. Tazeau, PhD 
ynt consulting, San Jose, Calif.
chair, Diversity Committee
APA Society of Clinical Geropsychology
October 2013

• Older Americans Behavioral Health Issue Brief 11: Reaching Diverse Older Adult Populations and Engaging Them in Prevention Services and Early Interventions (2011) (PDF, 1MB) 
  Administration on Aging/Substance Abuse and Mental Health Services Administration
  
  This issue brief identifies strategies to reach and engage diverse older adult populations in prevention services and early interventions to address behavioral health concerns. Also, this issue brief: describes the prevalence of behavioral health problems in diverse groups of older adults; identifies strategies for reaching and engaging older adults in behavioral health services; discusses the delivery of culturally appropriate behavioral health services; and offers examples of behavioral health programs that have successfully engaged diverse groups of older adults, including African-American, American Indian/Alaska Native (AI/AN), Asian-American, and Hispanic/Latino older adults; lesbian, gay, bisexual and transgender (LGBT) older populations; and older adults living in rural areas.
  
  

• Multicultural Competency in Geropsychology
  American Psychological Association Committee on Aging and its Working Group on Multicultural Competency in Geropsychology
  
  The purpose of this report is to: explore the key issues regarding the infusion of multicultural competence throughout geropsychology; make recommendations for future action addressing practice, research, education and training, and public policy issues; and inform psychologists of existing resources to improve their own multicultural competence in working with older adults.
  
  

• Bibliography of Research and Clinical Perspectives on LGBT Aging (2008) (PDF, 99KB)
  American Psychological Association Div. 44 (Society for the Psychological Study of Lesbian, Gay, Bisexual and Transgender Issues) Task Force on Aging
  
  This bibliography was compiled through multiple sources including databases, search engines and a variety of individuals and organizations that offered references and revisions. This bibliography will continue to be updated and posted at the American Psychological Association Div. 44 web site through the Div. 44 Task Force on Aging.
  
  

• Fact Sheet on Aging and Socioeconomic Status (2010)
  American Psychological Association Office on Socioeconomic Status (SES)
  
  Provides data on the SES status of older adults and how SES affects society and the lives of older adults. It also provides suggestions for including SES in research, practice and educational endeavors.
  
  

• Family Caregiver Briefcase — Variations for Practice for Culturally Diverse Groups (2011)
  American Psychological Association Presidential Task Force on Caregivers  
  
  The nature and outcomes of family caregiving are different for various sub-groups, depending on such factors as socioeconomic status; gender; age; cultural/ethnic traditions, values and beliefs; minority status; and degrees of acculturation and assimilation. In order to provide effective care to caregivers, psychologists need to be aware of and responsive to these nuances of culturally diverse groups.
  
  

• Teaching and Learning about Aging (2008)
  American Psychological Association Task Force on Diversity Education Resources 
  
  This bibliography provides references on aging, teaching about aging, organizations related to aging, resources for graduate-level education in gerontology and online resources for aging education.
  
  

• Transforming Mental Health Services for Older People: Lesbian, Gay, Bisexual and Transgender Challenges and Opportunities (2007)
  FORGE: Transgender Aging Network 
  
  Service providers often think about “minority” group members as challenges: How do we adapt our existing protocols and programs to meet the needs of these people over here who are different from our usual clients? Unfortunately, we frequently attempt to answer this question by trying to gain “cultural competency,” a code phrase that all too often stands for this directive: “substitute this (just slightly more nuanced) set of stereotypes for the set you have been using.” This approach neither serves individual clients — who can never be summed up by a single attribute, whether that be their race, age, gender, sexual orientation or psychiatric diagnosis — nor makes full use of the opportunities for systems improvement that diversity creates. This article offers alternatives to this standard (and inadequate) response to diversity by exploring four ways in which engaging aging diversity can actually improve both our services and the broader community.
  
  

• Diversity Advancement Toolkit: Strengthening Cultural Competence within National Aging Network, Area Agencies on Aging, Title VI Programs and Service Providers
  National Association of Area Agencies on Aging (n4a)
  
  The Toolkit is designed to support Area Agencies on Aging (AAAs) and Title VI programs in becoming more aware and knowledgeable about diversity issues within their operational environments. It is designed to provide tools for improving diversity practices and cultural competency.
  
  

• Stanford Geriatric Education Center
  
  A nationally recognized leader in the field of ethnogeriatrics, or health care for elders from diverse populations. Since SGEC was funded by the Bureau of the Health Professions (BHPr) in the Health Resources and Services Administration (HRSA) in 1987, hundreds of resources have been developed. A wealth of ethnogeriatric resources, including Ethnogeriatric Competencies for health care providers and including emergency preparedness; mental health, cultural and spiritual diversity in end of life, dementia and caregiving, health literacy and diabetes are available. 
  
  

• Curriculum in Ethnogeriatrics (2002) 2^nd edition
  Stanford University Collaborative of Ethnogeriatric Education 
  
  This second edition of the five modules in the Core Curriculum in Ethnogeriatrics was developed with support from the Bureau of Health Professions, Health Resources and Services Administration.
  
  

• Reference and Resource Guide for Working with Hispanic/Latino Older Adults, Based on Treatment Improvement Protocol 26: Substance Abuse Among Older Adults (2008)
  Substance Abuse and Mental Health Services Administration
  
  Offers practice guidelines for the identification, screening, assessment and treatment of the elderly for alcohol abuse and abuse of prescription drugs or over-the-counter drugs. Discusses outcomes and financial, ethical and legal issues.
  
  

• The Resource Centers for Minority Aging Research
  
  The mission of the Resource Centers for Minority Aging Research (RCMAR) is to decrease health disparities by: increasing the number of researchers who focus on the health of minority elders; enhancing the diversity in the professional workforce by mentoring minority academic researchers for careers in minority elders health research; improving recruitment and retention methods used to enlist minority elders in research studies; creating culturally sensitive health measures that assess the health status of minority elders with greater precision; and, increasing the effectiveness of interventions designed to improve their health and well-being.
  
  

• The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults (2012) (PDF, 14KB)
  Fredriksen-Goldsen, K.I., Kim, H-J., Emlet, C.A., Muraco, A., Erosheva, E.A., Hoy-Ellis, C.P., Goldsen, J., & Petry, H.
  
  The report is based on the Caring and Aging with Pride project, which is the first national federally- funded project examining the aging and health of over 2,500 LBGT adults ages 50 to 95. It reveals significant health disparities impacting LGBT older adults as they age, including disability, physical and mental distress, victimization, discrimination and lack of access to supportive aging and health services. LGBT older adults are also resilient. A large majority of LGBT older adults (91 percent) engage in wellness activities and moderate physical exercise (82 percent). Thirty-eight percent of LGBT older adults attend spiritual or religious activities at least once monthly and 90 percent feel a sense of belonging to their communities. As the older adult population continues to grow in number and diversity, it remains imperative for public policy, community services, and research to target the distinct needs of sub-populations within the older adult demographic. Health disparities must be eliminated to effectively respond to the aging crises in the lesbian, gay, bisexual and transgender communities.
  
  

• The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (2012) 
  Institute of Medicine
  
  Chapter 2 provides information on the prevalence of mental health and substance use conditions in racial and ethnic groups.
  
  

• Toward an Inclusive Psychology: Infusing the Introductory Psychology Textbook with Diversity Content (2003) (PDF, 3MB)
  APA Commission on Ethnic Minority Recruitment, Retention and Training in Psychology Task Force Textbook Initiative Work Group
  
  This American Psychological Association document is designed to provide suggestions and examples for publishers, authors and instructors in order to help them advance psychology as an inclusive science. It is intended to provide concrete suggestions and examples to aid in the infusion of race/ethnicity, culture, gender, sexual orientation, disability and aging into the content of introductory psychology textbooks and coursework. 

• Treatment of depression in low income older adults  
  Areán, P.A., Gum, A., McCulloch, C. E., Bostrom, A., Gallagher-Thompson, D., & Thompson, L. (2005). Psychology and Aging, 20 (4), 601-609. doi: 10.1037/0882-7974.20.4.601
  
  The purpose of this study was to compare cognitive-behavioral group therapy (CBGT), clinical case management (CCM) and their combination (CBGT + CCM) to treat depression in low-income older adults (60+). Sixty-seven participants with major depressive disorder or dysthymia were randomly assigned and entered into 1 of the 3 treatment conditions for 6 months. They were followed for 18 months after treatment initiation on depression and functional outcomes. CCM and CBGT + CCM led to greater improvements in depressive symptoms than CBGT, but CBGT led to greater improvements in physical functioning. All three conditions resulted in similar reduction of needs. Findings suggest that disadvantaged older adults with depression benefit from increased access to social services either alone or combined with psychotherapy.
  
  
• Treating depression in disabled, low-income elderly: a conceptual model and recommendations for care 
  Areán, P.A., Mackin, S., Vargas-Dwyer, E., Raue, P., Sirey, J.A., Kanellopolis, D., & Alexopoulos, G.S. (2010). International Journal of Geriatric Psychiatry, 25(8), 765-769. doi: 10.1002/gps.2556 
  
  The treatment of depression in low-income older adults who live in poverty is complicated by several factors. Poor access to resources, disability and mild cognitive impairment are the main factors that moderate treatment effects in this population. Interventions that not only address the depressive syndrome but also manage social adversity are sorely needed to help this patient population recover from depression. This paper is a literature review of correlates of depression in late life. In the review a treatment model is proposed that combines case management (CM) to address social adversity with problem solving treatment (PST) to address the depressive syndrome. The authors present the case of Mr. Z, an older gentleman living in poverty who is also depressed and physically disabled. The case illustrates how the combination of CM and PST can work together to ameliorate depression. The combination of age, disability and social adversity complicates the management and treatment of depression. CM and PST are interventions that work synergistically to overcome depression and manage social problems. 
  
  
• Priorities for action in a rural older adults study   
  Averill, J.B. (2012). Family & Community Health, 35 (4), 358–372. doi: 10.1097/FCH.0b013e318266686e 
  
  This article reports the findings from a recent study of older adults in the rural southwestern United States and discusses practice and research implications. The aim of the study was to analyze health disparities and strengths in the contexts of rurality, aging, a depressed economy and limited health resources. Identified themes needing action included sustained access to prescriptions, transportation solutions for older adults in isolated communities, inadequate access to care, poor infrastructure and coordination of services, scarce assisted living and in-home care for frail older adults, and barriers related to culture, language and economics. 
  
  
• Ethical issues in cross-cultural neuropsychology 
  Brickman, A. M., Cabo, R., & Manly, J. J. (2006). Applied Neuropsychology, 13 (2), 91-100. doi:10.1207/s15324826an1302_4 
  
  Clinical neuropsychologists who assess patients from diverse cultural and linguistic backgrounds face unique ethical challenges. Four critical questions relevant to ethics of cross-cultural neuropsychology are addressed: (a) Should culture or race be considered in neuropsychological testing? (b) Should race- and ethnicity-specific normative data be used in the clinical neuropsychological evaluation? (c) Who is competent to design and translate tests for ethnic minority groups and non-English speakers and who is competent to administer and interpret them? And, (d) Are neuropsychology training programs adequately preparing clinicians to be competent in the assessment of cross-cultural groups? The overall aims of the article are to highlight the complexity of these clinical and ethical issues, to provide comprehensive and balanced information to help guide clinician choices, and to stimulate future research in this area.
  
  
• The health and social service needs of gay and lesbian elders and their families in Canada 
  Brotman, S., Ryan, B., & Cormier, R. (2003). The Gerontologist, 43(2) , 192-202. doi: 10.1093/geront/43.2.192 
  
  This article reports the findings of a study, undertaken in 2000, whose purpose was to gather information about the experiences and realities of gay and lesbian seniors and their families from across Canada in accessing a broad range of health and social services in the community, and to examine the role of health care and social service organizations in shaping access and service delivery. This study used a qualitative exploratory design based on focus group interviews. Perspectives of older gay men and lesbians and their families involved in organizations addressing these issues, as well as professionals from both gay and lesbian health organizations and mainstream elder care organizations were sought. Specific reference was made to the impact of discrimination on the health and access to health services of these populations. Issues relating to invisibility, historic and current barriers to care, and the nature of service options are identified. Recommendations for change are highlighted, including those related to best practice programs and policies in the long-term care sector. 
  
  
• Building a registry of research volunteers among older urban African Americans: Recruitment processes and outcomes from a community-based partnership 
  Chadiha, L.A., Washington, O.G.M., Lichtenberg, P.A., Green, C.R., Daniels, K.L., & Jackson, J.S. (2011). The Gerontologist , 51(1) , S106-S115. doi: 10.1093/geront/gnr034 
  
  An emerging strategy for increasing public participation in health research is volunteer registries. Using a community-based participatory research framework, recruitment processes and outcomes in building a research volunteer registry of older urban African-Americans are described. The specific research question examined retrospectively was: How does a community outreach partnership between older residents and academic researchers of the Healthier Black Elders Center facilitate recruitment of older urban African-Americans for a research volunteer registry? Program evaluation methods, specifically the logic model, were adopted for clarifying how community outreach health education activities supported development of a research volunteer registry of older urban African-Americans. Paralleling the seven years in which an annual health reception was held, enrollees in a research volunteer registry increased from 102 to 1,273 enrollees. Targeted outreach to underrepresented groups to build a registry of volunteers for health research may be a promising strategy for addressing recruitment disparities in African-Americans' research participation.
  
  
• Acculturation and its effect on depressive symptom structure in a sample of Mexican American Elders  
  Chiriboga, D.A., Banks, S., & Kim, G. (2007). Hispanic Journal of Behavioral Sciences, 29(1) , 83-100. doi: 10.1177/0739986306295875 
  
  In this study, depressive symptoms reported by Mexican-American elders who scored higher and lower on a linguistic acculturation scale were compared. Prevalence, equality of covariance matrices, equality of error variances and factor structures were examined for the 20 items included in the Center for Epidemiologic Studies Depression (CES-D) Scale. The sample consisted of 3,050 community-dwelling Mexican-Americans from five states. Significant differences were found on all parameters, indicating that level of acculturation is associated with pervasive differences in the way items are endorsed on the most commonly used inventory of depressive symptoms. Results add to literature suggesting that there may not be a universal structure to symptoms. Higher or lower scores may have different implications for people representing different cultures and/or stages of acculturation, something that both researchers and clinicians should be sensitive to when interpreting results of screening tests. 
  
  
• Minority and cultural issues in late-life depression 
  Chiriboga, D.A., Yee, B.W.K., Jang, Y. (2005). Clinical Psychology: Science and Practice, 12(3) , 358-363. doi: 10.1093/clipsy/bpi042 
  
  Disparities in the identification and treatment of behavioral health problems such as depression have only recently come to the attention of policymakers, researchers and practitioners. This paper reviews currently available information on critical elements of cultural competence for clinical practice, including not only organizational standards but also the standards recommended for individual providers. Factors that may distinguish a minority elder from non-Hispanic white clients are discussed, as well as potential problems with psychosocial assessment tools.
  
  
• Utilization of Alzheimer's disease community resources by Asian-Americans in California 
  Chow, T.W., Ross, L., Fox, P., Cummings, J.L., & Lin, M.M. (2000). International Journal of Geriatric Psychiatry, 15(9) , 838-47. doi : 10.1002/1099-1166(200009)15:9<838::AID-GPS209>3.0.CO;2-U 
  
  Alzheimer's disease is as prevalent among Asian ethnic minority groups as among Caucasians. Asian groups' utilization of available Alzheimer's disease services in California were explored using a uniquely large sample of Asian-Americans. The Minimum Uniform Dataset includes data from nine California Alzheimer's Disease Diagnostic and Treatment Centers. Of the 9,451 cases included in the Minimum Utilizable Dataset, 4.2 percent were Asian (primarily Chinese), 0.8 percent Filipino, 0.3 percent Pacific Islander, and 75.9 percent Caucasian. In comparison to their numbers within the nine California countries served, Asian ethnic elders were underrepresented in enrollment by approximately 50 percent, except at one center where all staff were bilingual. The centers referred a significantly greater proportion of Asian than Caucasian patients for financial help (47.8 vs. 7.4 percent, P < 0.001), case management (47.8 vs. 22.3 percent, P < 0.001), and to Alzheimer's disease day care (41.3 vs. 28.4 percent, P < 0.05). A significantly greater proportion of Asian caregivers received referrals to caregiver resource centers (32.6 vs. 61.3 percent, P < 0.001) and financial help (29.6 vs. 4.7 percent, P < 0.001). A smaller proportion of Asian patients received referrals to home health services than Caucasians (4.3 vs. 14.9 percent, P < 0.05). Filipino patients were also referred more frequently to financial assistance than Caucasians (P < 0.05). Asians and Pacific Islanders under-enroll at centers specializing in AD care. Bilingual staff at centers specializing in dementia care, training for community physicians who treat these patients and the establishment of caregiver support groups within Asian and Pacific Islander communities may enhance the enrollment of these elders. AD care centers in areas supporting Asian and Filipino families may need to concentrate resources on providing financial assistance in case management.
  
  
• Exploring interventions for LGBT caregivers: Issues and examples 
  Coon, D.W. (2005). Journal of Gay & Lesbian Social Services: Issues in Practice, Policy & Research, 18(3-4) , 109-128. doi: 10.1300/J041v18n03_07 
  
  LGBT caregiving for midlife and older adults facing chronic illness or disability as well as the development and evaluation of interventions targeting LGBT caregivers remains fundamentally unexplored. Caregivers regardless of their sexual orientation or gender identity often juggle multiple roles and responsibilities leading to increased stress and distress. However, largely due to discrimination and discriminatory policies, many LGBT caregivers face barriers at multiple levels of service provision that can exacerbate stress and negatively impact caregiver and care recipient quality of life. This article highlights many of these obstacles and provides examples of intervention strategies designed to assist LGBT caregivers ranging from interventions aimed at the individual and interpersonal levels of service provision to changes needed at the social policy level. As an example of an individual or interpersonal level of intervention designed to assist LGBT caregivers, the SURE 2 framework is presented and more thoroughly discussed. Given the diversity of the LGBT community, the article ends with ways to extend or adapt SURE 2 as well as suggesting that the time has come to develop and test a variety of interventions for LGBT caregivers. 
  
  
• Adapting homework for an older adult client with cognitive impairment 
  Coon, D.W., Thompson, L.W., & Gallagher-Thompson, D. (2007). Cognitive and Behavioral Practice, 14(3) , 252-260. doi: 10.1016/j.cbpra.2006.10.006 
  
  There is growing evidence that psychosocial treatments incorporating behavioral intervention strategies can be effective in the treatment of depression in older adults with cognitive impairment. However, less work with such cases has focused on the use of cognitive interventions in tandem with these behavioral intervention strategies. This case study describes how cognitive behavioral intervention strategies and related homework assignments were tailored and integrated to successfully treat depressive symptoms in an older African American diagnosed with probable Alzheimer's disease. Examples of the homework strategies utilized are introduced by phase of treatment. We also discuss ways to overcome barriers to homework completion as well as methods to incorporate the client's sociocultural context and personal history into homework.
  
  
• Treating the aged in rural communities: The application of cognitive-behavioral therapy for depression 
  Crowther, M.R., Scogin, F., & Norton, M.J. (2010). Journal of Clinical Psychology, 66(5) , 502-512. doi: 10.1002/jclp.20678 
  
  Many rural communities are experiencing an increase in their older adult population. Older adults who live in rural areas typically have fewer resources and poorer mental and physical health status than do their urban counterparts. Depression is the most prevalent mental health problem among older adults, and 80 percent of the cases are treatable. Unfortunately, for many rural elders, depressive disorders are widely under-recognized and often untreated or undertreated. Psychotherapy is illustrated with the case of a 65-year-old rural married man whose presenting complaint was depressive symptoms after a myocardial infarction and loss of ability to work. The case illustrates that respect for rural elderly clients' deeply held beliefs about gender and therapy, coupled with an understanding of their limited resources, can be combined with psychoeducational and therapeutic interventions to offer new options. 
  
  
• Aspects of mental health among older lesbian, gay, and bisexual adults 
  D'Augelli, A.R., Grossman, A.H., Hershberger, S.L., & O'Connell, T.S. (2001). Aging & Mental Health, 5(2) , 149-158. doi: 10.1080/13607860120038366 
  
  Examined aspects of mental health among 416 lesbian, gay, and bisexual adults aged 60–91 yrs old, attending social and recreational programs. Mental health indicators were perceived mental health status; self-esteem; internalized homophobia; loneliness; alcohol and drug abuse; and suicidality. Better mental health was correlated with higher self-esteem, less loneliness and lower internalized homophobia. Compared to women, men reported significantly more internalized homophobia, alcohol abuse, and suicidality related to their sexual orientation. Less lifetime suicidal ideation was associated with lower internalized homophobia, less loneliness, and more people knowing about participants' sexual orientation. 
  
  
• Psychotherapy with lesbian, gay, bisexual and transgender older adults 
  David, S. & Cernin, P. A. (2008). Journal of Gay & Lesbian Social Services, 20 (1-2), 31-49. doi:10.1080/10538720802178908 
  
  A small literature has addressed psychotherapy with lesbian, gay, bisexual and transgender (LGBT) samples over the past two decades. Older adults have also been investigated in a growing number of psychotherapy research studies. However, psychotherapy specifically with LGBT older adults has not received adequate investigation. This review relies on converging lines of research to provide an integrated discussion of evidence-based psychological treatments (EBTs) with current research and clinical observations in the field of gerontology and suggests ways in which these topics can inform psychotherapy practice with LGBT older adults. We summarize current research on aging in several areas of practical interest to psychotherapists seeking to apply EBTs in their work with LGBT older adults. These areas include: adult development, coping, stigmatization, social context and the effects of cohort membership. The results of these studies belie stereotypes regarding both the aging process, in general, and more specifically LGBT older adulthood, with significant implications for the practice of psychotherapy. EBTs are adaptable to a variety of issues encountered in later life by LGBT older adults and these modifications to therapeutic technique are addressed throughout. 
  
  
• Stress and coping among gay men: age and ethnic differences 
  David, S. & Knight, B. G. (2008). Psychology and Aging, 23 (1), 62-69. doi:10.1037/0882-7974.23.1.62
  
  Previous studies suggest that perceived stigmatization of sexual minority status, ethnicity and age are associated with negative mental health outcomes, and other studies suggest that coping styles may influence these outcomes. However, no studies have examined these relationships among gay men of varying ethnicities and age groups. Three hundred eighty-three Black and White, younger, middle-aged and older adult gay men completed measures of perceived stigmatization, coping style and mental health outcomes. Black older adult gay men reported significantly higher levels of perceived ageism than the older White group, significantly higher levels of perceived racism than the younger Black group, significantly higher levels of homonegativity than the younger Black and the White groups, and were more likely to use disengaged coping styles than White gay men. However, Black older adult gay men did not experience significantly higher levels of negative mental health outcomes. Results suggest that further research should examine how older Black gay men, who perceive higher levels of stigma while reporting greater use of less effective coping styles, do not appear to be experiencing more negative mental health outcomes as a result. 
  
  
• Preferences for mental health care: A comparison of older African Americans and older Caucasians 
  Dupree, L.W., Watson, M.A., & Schneider, M.G. (2005). Journal of Applied Gerontology, 24, 296-210. doi: 10.1177/0733464804272100 
  
  Research on mental health service utilization patterns has shown that older adults underutilize outpatient services, particularly in minority populations. Greater reliance on inpatient services may result when a mental health problem can no longer be ignored. The goal of this study was to compare the attitudes and beliefs of African-American and Caucasian older adults about mental health care and preferred providers. A 47-item survey was administered to a convenience sample of 1,598 primarily African-Americans, recruited at 40 sites, including the study sample of 726 people older than age 50. Results showed that respondents of both races preferred advice from their family doctor, clergy, or a family member. African-Americans preferred services in their doctor's or clergy's office, whereas Caucasians preferred a professional service provider's office. Findings suggest that providers and policy makers consider the impact of age, culture and ethnicity on mental health services provision. 
  
  
• Social network typologies and mental health among older adults
  Fliori, K.L., Antonucci, T.C., & Cortina, K.S. (2006). The Journal of Gerontology: Series B Psychological Sciences, 61(1) , 25-32.
  
  In this study, the authors test the robustness of previous social network research and extend this work to determine if support quality is one mechanism by which network types predict mental health. Participants included 1,669 adults aged 60 or older from the Americans' Changing Lives study. Using cluster analysis, diverse, family and friends network types, consistent with the work by Litwin from 2001, were found. However, two types of restricted networks, rather than just one were found: a nonfamily network and a nonfriends network. Depressive symptomatology was highest for individuals in the nonfriends network and lowest for individuals in the diverse network. Positive support quality partially mediated the association between network type and depressive symptomatology. Results suggest that the absence of family in the context of friends is less detrimental than the absence of friends in the context of family, and that support quality is one mechanism through which network types affect mental health.
  
  
• Tailoring psychological interventions for ethnically diverse caregivers 
  Gallagher-Thomson, D., Haley, W., Guy, D., Rupert, M., Arguelles, T., Zeiss, L., Long, C., Tennstedt, S., & Ory, M. (2003). Clinical Psychology: Science and Practice, 10 , 423- 438. doi: 10.1093/clipsy.bpg042 
  
  Alzheimer's disease and other dementias are common disorders that widely affect older adults of all races and ethnicities. Although there has been considerable research focusing on the stress experienced by family caregivers of patients with dementia, there has been little work to guide clinicians in tailoring interventions to the special needs of racially and ethnically diverse families. This paper reviews guidelines for creating culturally competent interventions, as well as reviewing the literature on racial, ethnic and cultural differences in the stress associated with caregiving for a family member with dementia. The paper then presents three intervention programs (adapted from existing treatments) that were tailored to be sensitive to cultural issues in caregiving among African-Americans, Cuban-Americans, and Mexican-Americans. Results and directions for future research gathered from these intervention programs are presented and implications for clinicians and researchers are discussed.
  
  
• Why multicultural issues matter to practitioners working with older adults 
  Hinrichsen, G. (2006). Professional Psychology: Research and Practice, 37 (1), 29-35. doi:10.1037/0735-7028.37.1.29 
  
  How are the American Psychological Association's multicultural practice guidelines relevant to those who provide clinical services to older adults? Issues of race and ethnicity figure in the lives of older adults and their service providers in ways that may not be readily apparent. In this article, the author reviews facts about minority aging along with clinical examples to illustrate issues older adults confront in negotiating racial, ethnic and age differences between themselves and others, including service providers. Current professional efforts to enhance sensitivity to late-life diversity issues are reviewed, as are resources on which the practicing psychologist can draw. Recommendations are made regarding how psychologists can gain knowledge, enrich teaching and supervision, and encourage conversation with clients and colleagues about multicultural aging.
  
  
• Religiosity, adherence to traditional culture, and psychological well-being among African American elders 
  Jang, Y., Borenstein, A., Chiriboga, D., Phillips, K., & Mortimer, J. (2006). Journal of Applied Gerontology , 25 (5), 343-355. doi: 10.1177/0733464806291934 
  
  To expand our knowledge on the role of religiosity in African American culture, this study assessed the associations among religiosity, adherence to traditional African-American culture and psychological well-being. Regression models of psychological well-being, indexed with depressive symptoms and life satisfaction, were tested using a representative sample of 255 community-dwelling African-American older adults in Hillsborough County, Fla. The direct effect of religiosity was found to be significant for both depressive symptoms and life satisfaction. A significant interaction between religiosity and adherence to African-American culture was observed in the prediction of life satisfaction. Further analyses indicated that the positive effect of religiosity on life satisfaction was stronger in the more traditional group compared to that in the less traditional group. The results demonstrate that the benefits of religiosity do not exist uniformly across all African Americans but vary by the level of adherence to traditional culture.
  
  
• Conceptual and methodological linkages in cross-cultural groups and cross-national aging research 
  Jackson, J.S. (2002). Journal of Social Issues , 58 ,825-835. doi: 10.1111/1540-4560.00292 
  
  The international growth and the expected size of older populations require effective research strategies in life-course development and aging research across the globe. New conceptual frameworks and empirical research approaches are needed that are sensitive to similarities and differences in aging related processes across national, ethnic and cultural group boundaries. These models and research approaches should contribute to distinguishing, "aging-in-place-of-origin" froth "aging-out-of-place-of-origin," and the influences of such factors as nationality, culturally affected behaviors, acculturation and intra-familial processes, on intra- and cross-country comparisons of aging related phenomena. Brief examples of how these new frameworks can be applied in addressing both theoretical and practical service issues are drawn from the aging research foci of the articles in this issue. 
  
  
• Age cohort, ancestry, and immigrant generation influences in family relations and psychological well-being among Black Caribbean family member   
  Jackson, J.S., Frosythe-Brown, I., & Govia, I.O. (2007). Journal of Social Issues , 63 , 729-743. doi: 10.1111/j.1540-4560.2007.00533.x 
  
  Immigration is contributing to the U.S. population becoming increasingly ethnically diverse. This article examines the role of family relations and well-being among different generations of Black Caribbean immigrants. Family disruptions, such as migration, can have complex effects on the support networks and emotional well-being of family members. Data from a recently completed national study of American Blacks in the United States, however, reveal significant similarities across ancestry and immigrant status in family contact, solidarity and well-being. It is concluded that intrafamilial relations may serve to overcome barriers of geographical distance in providing comparable levels of contact, solidarity and well-being for both U.S.-born and immigrant Black Caribbean family members of different generations. Because of the increasing numbers of immigrant elders, these sources of family support will become increasingly more important in bridging the gaps between government resources and needed assistance in an aging society. 
  
  
• Race and unhealthy behaviors: Chronic stress, the HPA Axis, and physical and mental health disparities over the life course 
  Jackson, J.S., Knight, K.M., & Rafferty, J.A. (2010). American Journal of Public Health , 100 (5), 933-939. doi: 10.2105/AJPH.2008.143446 
  
  The authors sought to determine whether unhealthy behaviors play a stress-buffering role in observed racial disparities in physical and mental health. Logistic regressions by race were conducted on data from the first two waves of the Americans' Changing Lives Survey to determine whether unhealthy behaviors had buffering effects on the relationship between major stressors and chronic health conditions, and on the relationship between major stressors and meeting the criteria for major depression. Among Whites, unhealthy behaviors strengthened the relationship between stressors and meeting major-depression criteria. Among Blacks, however, the relationship between stressors and meeting major-depression criteria was stronger among those who had not engaged in unhealthy behaviors than among those who had. Among both race groups there was a positive association between stressors and chronic health conditions. Among Blacks there was an additional positive association between number of unhealthy behaviors and number of chronic conditions. Those who live in chronically stressful environments often cope with stressors by engaging in unhealthy behaviors that may have protective mental-health effects. However, such unhealthy behaviors can combine with negative environmental conditions to eventually contribute to morbidity and mortality disparities among social groups. 
  
  
• Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary care 
  Jimenez, D.E., Bartels, S.J., Cardenas, V., Dhaliwal, S.S., Alegria, M. (2012). The American Journal of Geriatric Psychiatry, 20(6) ,533-42. doi: 10.1097/JGP.0b013e318227f876 
  
  Beliefs concerning the causes of mental illness may help to explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their white counterparts. This study applies the cultural influences on mental health framework to identify the relationship between race/ethnicity and differences in 1) beliefs on the cause of mental illness, 2) preferences for type of treatment, and 3) provider characteristics. Analyses were conducted using baseline data collected from participants who completed the cultural attitudes toward healthcare and mental illness questionnaire, developed for the Primary Care Research in Substance Abuse and Mental Health for the Elderly study, a multisite randomized trial for older adults (65+) with depression, anxiety or at-risk alcohol consumption. The final sample consisted of 1,257 non-Latino whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos. African-Americans, Asian-Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared with non-Latino whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences and preferred characteristics of healthcare providers. This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services. 
  
  
• The black/white disability gap: Persistent inequality in later life? 
  Kelley-Moore, J. A., & Ferraro, K. F. (2004). Journal of Gerontology: Social Sciences, 59 (4), S34-S43. doi:10.1093/geronb/59.1.S34 
  
  Previous research on differences between Black and White older adults has produced inconsistent results on whether a gap in disability exists and whether it persists over time. The present research identifies several reasons for the inconsistent results to date and examines Black/White differences in disability trajectories over six years. Data from the North Carolina Established Populations for the Epidemiologic Studies of the Elderly (1986–1992) are used to estimate the disability gap and trajectory over time for both Black and White older adults.
  
  Results indicate that a disability gap between Black and White adults exists, but after socioeconomic resources, social integration and other health indicators are adjusted for, the trajectories of disability by race are not significantly different. Controlling for incident morbidity over time accounts for the significant difference in level of disability between the two groups.
  
  This research supports the “persistent inequality” interpretation, indicating that Black adults have higher morbidity and disability earlier in life compared with White adults, and that the gap neither converges nor diverges over time.
  
  
• Promoting cognitive health in diverse populations of older adults
  Logsdon, R.G., Sharkey, J.R., & Hochhalter, A.K. (Eds.). (2009). (Special Issue) The Gerontologist, 49 , Number S1
  
  This special issue is devoted to cognitive health, a major factor in ensuring quality of life and preserving independence. Cognitive health has been identified as a priority area for aging and public health through national efforts such as the National Institutes of Health's Cognitive and Emotional Health Project ( Hendrie et al., 2006 ) and the Centers for Disease Control and Prevention's (CDC) Healthy Brain Initiative ( Anderson & McConnell, 2007 ). This increased recognition also aligns with growing awareness of the significant health, social and economic burden associated with cognitive impairments; rising concerns and fears about potential loss of cognitive functions with age; and increasing demands of family and professional caregivers. The U.S. population as a whole is aging at an unprecedented rate, and with that change comes an increasing incidence of cognitive impairments, such as Alzheimer's disease and other dementias. As concluded in the Forum of this issue, few studies have systematically studied the public's perceptions about cognitive health, and we lack information to understand perceptions across diverse demographic and cultural groups. The core set of articles in this special issue describe the results of this work. Specifically, these articles describe the purpose and methods used, along with the findings related to how the public describes cognition, what the public perceives about cognitive health and related risk factors, and how perceptions about cognition vary across diverse groups and regions. Additionally, the findings from several studies examining physical activity and cognition are reported, and their programmatic implications are described. The issue concludes with an editorial highlighting various themes that emerge from the articles.
  
  
• Disability among older American Indians and Alaska Natives: Disparities in prevalence, health-risk behaviors, obesity, and chronic conditions
  Okoro, C.A., Denny, C.H., McGuire, L.C., Balluz, L.S., Goins, R.T., & Mokdad, A.H. (2007). Ethnicity & Disease, 17(4), 686–692.
  
  The purpose of this study was to estimate the prevalence of disabilities among older American Indians and Alaska Natives (AIANs) and compare these estimates with those of other major racial/ ethnic groups and to estimate, within the population with disabilities, the health-risk behaviors, obesity, and chronic conditions of older AIANs and compare them with estimates for other racial/ethnic groups. Utilizing a state-based surveillance system that collects data on a monthly basis, an independent probability sample of households with telephones among the noninstitutionalized population aged > or =18 years was selected. Data on 434,972 noninstitutionalized adults aged > or =50 years from the 2003-2005 Behavioral Risk Factor Surveillance System were analyzed. Among older AIAN adults, the unadjusted prevalence of disability (38.4 percent) was higher than among Whites (29.7 percent), Blacks (33.5 percent), Asians (15.6 percent), and Hispanics (26.9 percent). Among older adults with disabilities, AIANs were younger than their counterparts in other groups and were as likely to be male as female. After adjustment for age and self-rated health, both AIAN men and women with disabilities had the highest prevalence of current smoking, heart disease and asthma. Efforts to prevent, delay and reduce disabilities and associated secondary conditions in persons with disabilities must be culturally sensitive and targeted toward reducing racial/ethnic disparities in health-risk behaviors and chronic conditions.
  
  
• The mediating role of loneliness in the relation between social engagement and depressive symptoms among older Korean Americans: do men and women differ? 
  Park, N.S., Jang, Y., Lee, B.S., Haley, W.E., & Chiriboga, D.A. (2012). The Journals of Gerontology, Series B: Psychological Sciences and Social Services, 68(2) , 193-201. doi: 10.1093/geronb/gbs062
  
  This study conceptualized loneliness as a mediator in the relation between social engagement and depressive symptoms and explored gender differences in the mediation model. Various indices of social engagement were considered including living arrangement, social network and activity participation. Using data from 674 community-dwelling Korean American older adults, the mediation effect of loneliness in the relation between each of 3 indices of social engagement (not living alone, social network and activity participation) and depressive symptoms was examined. Subsequently, gender differences in the mediation model were examined. As hypothesized, loneliness was found to mediate the relation between each of the indices of social engagement and depressive symptoms in both men and women. Gender differences in the strength of mediating effects were also observed; the effect of living alone was more likely to be mediated by loneliness among men, whereas women showed greater levels of mediation in the models with social network and activity participation. The findings suggest that loneliness may explain the mechanism by which deficits in social engagement exerts its effect on depressive symptoms and that gender differences should be considered in interventions targeting social engagement for mental health promotion.
  
  
• Life Events in Older Adults with Intellectual Disabilities: Differences between adults with and without Down Syndrome.
  Patti, P. J., Amble, K. B., & Flory, M. J. (2005). Journal of Policy and Practice in Intellectual Disabilities, 2 , 149–155. doi: 10.1111/j.1741-1130.2005.00023.x
  
  Life events can have a negative impact on older adults with intellectual disabilities (ID) and are associated with depression and functional decline. Research on life events in people with ID revealed few reports that investigated life events exposure in people with Down syndrome (DS). The number and types of life events experienced in a cohort of 211 adults with ID (108 with DS, and 103 without DS) older than 50 years of age were studied. Data on life events exposure were collected from clinical records and informant interviews. The findings revealed that persons with DS in the sixth decade of life experienced a significantly greater number of life events and changes than adults without DS of similar or older ages. The number of relocations and medical events were found to be significantly greater in those with DS, whereas adults without DS experienced a significantly lower number of occurrences in all the life events categories studied. Adults with DS 50–59 years of age experienced a greater number of life events than did a group of adults without DS 50 years of age and older. Of the categories of life events investigated, changes in environment, experienced losses/separations, and medical events appear to be a common occurrence in the lives of older adults with DS. Functional decline, which commonly occurs during the dementia process, was seen as directly related to the prevalence and types of life events that adults with DS experience. 
  
  
• DSM-5 Research: Assessing the mental health needs of older adults from diverse ethnic backgrounds 
  Rose, A.L., & Cheung, M. (2012). Journal of Ethnic and Cultural Diversity in Social Work, 21(2) , 144-167. doi: 10.1080/15313204.2012.673437 
  
  This article analyzes current trends and limitations in the design of the Diagnostic and Statistical Manual of Mental Disorders (DSM ) with a focus on its application to older adults from diverse ethnic backgrounds. An analysis of 54 articles published between 2001 and 2011 in four social science databases that discussed DSM and its applicability to assessing ethnically diverse older adults' mental health revealed five major themes: (1) assessment issues related to acculturation, (2) limitations with “culture” elements, (3) health disparities, (4) evidence-based practice with dementia, and (5) prevalence of anxiety and depression. Contributors to the DSM -5 must examine limitations, be mindful of cultural elements, and formulate culturally and age-sensitive diagnostic criteria. It is suggested that cultural competence trainings focus on the needs of elderly of color to help this population express culturally relevant and personally unique experiences in the diagnostic process. These considerations must also be inclusive of national and international populations facing mental health challenges.
  
  
• Access barriers to mental health services for older adults from diverse populations: perspectives of leaders in mental health and aging.  
  Solway, E., Estes, C.L., Goldberg, S., & Berry, J. (2010). J ournal of Aging and Social Policy, 22(4) , 360-78. doi: 10.1080/08959420.2010.507650 
  
  This project is based on the results of telephone surveys with 52 local, state and national informed respondents including policymakers, county leaders, planners and advocates in mental health and aging with a particular focus on the states of California and Florida. This article addresses challenges to access to mental health services for diverse older adults including barriers related to race and ethnicity, socioeconomic status, location, age, gender, immigrant status, language, sexual orientation and diagnosis. The article also highlights broad themes that emerged including (1) the importance of outreach and transportation tailored to diverse elders, and (2) recruitment of diverse staff and training related to diversity. The article concludes with policy and practice recommendations to reduce these disparities in access to mental health services for diverse populations of older adults.
  
  
• Curricular framework: Core competencies in multicultural geriatric care 
  Xakellis, G., Brangman, S. A., Ladson Hinton, W., Jones, V. Y., Masterman, D., Pan, C. X., Rivero, J., Wallhagen, M., & Yeo, G. (2004). Journal of the American Geriatric Society, 52 , 137-142. doi: 10.1111/j.1532-5415.2004.52024.x 
  
  Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula. 

"Mental Health, Intellectual Disabilities, and the Aging Process"

Davidson, P. W., Prasher, V. P., & Janicki, M. P. (Eds). (2003). Oxford: Blackwell Publishing, Ltd. 

This book is the third in a series with the International Association for the Scientific Study of Intellectual Disabilities designed to address the issues of health, adult development and aging among persons with intellectual disabilities. For many years it has been recognized that some adults with intellectual disabilities are at elevated risk for mental and behavioral health problems. Often the aging process can complicate the identification, diagnosis, treatment and prevention of this type of dual diagnosis and present complex challenges to clinicians and carers. This book is designed as a practical resource for those involved with the support, care and treatment of persons with intellectual disabilities, and should prove particularly useful as this community achieves increased longevity. The book is divided into three parts: Prevalence and Characteristics; Diagnosis and Treatment; and Service System Issues.

"Aging and Diversity: An active learning experience (2 nd ed.)"

Mehrotra, C.M., & Wagner, L.S. (2008). New York: Routledge. 

Completely rewritten, this new edition addresses key topics in diversity and aging, such as gender, race or ethnicity, religious affiliation and more. These elements convey the complexities that provide both challenges to meet the needs of diverse populations and opportunities to learn how to live in a pluralistic society. Rather than simply transmitting information, the authors place ongoing emphasis on developing readers' knowledge and skills, fostering higher-order thinking and encouraging exploration of personal values and attitudes. Distinctive features include: chapter-opening vignettes that illustrate how the issues to be discussed apply to diverse elders; active learning experiences that invite readers to interview diverse elders and give analysis of case studies; chapter quizzes with keys that facilitate further learning; and suggested readings and audiovisual resources that serve as a guide to additional information. Readers will understand and apply key concepts and principles in ways that will not only improve the lives of older people they serve, but will also enhance their own aging experience.

"Handbook of Minority Aging"

Whitfield, K., & Baker, T. (2013). New York: Springer Publishing Company

This text provides up-to-date, multidisciplinary, and comprehensive information about aging among diverse racial and ethnic populations in the United States. It is the only book to focus on paramount public health issues as they relate to older minority Americans, and addresses social, behavioral and biological concerns for this population. The text distills the most important advances in the science of minority aging and incorporates the evidence of scholars in gerontology, anthropology, psychology, public health, sociology, social work, biology, medicine and nursing. Additionally, the book incorporates the work of both established and emerging scholars to provide the broadest possible knowledge base on the needs of and concerns for this rapidly growing population. Chapters focus on subject areas that are recognized as being critical in understanding the well being of minority elders. These include sociology (Medicare, SES, work and retirement, social networks, context/neighborhood, ethnography, gender, demographics), psychology (cognition, stress, mental health, personality, sexuality, religion, neuroscience, discrimination), medicine/nursing/public health (mortality and morbidity, disability, health disparities, long-term care, genetics, dietary issues, health interventions, physical functioning), social work (caregiving, housing, social services, end-of-life care), and many other topics. The book focuses on the needs of four major ethnic groups: Asian/Pacific Islander, Hispanic/Latino, African-American, and Native American elders.

"Ethnicity and the dementias (2^nd ed.)"

Yeo, G. & Gallagher-Thompson, D. (Eds.), (2006). NY: Taylor & Francis Group.

According to the United States census bureau, the Hispanic American population constitutes the largest growing minority group in the United States. Although recent efforts to develop effective strategies to assist the caregivers of individuals with Alzheimer's disease are proving to be successful, it appears that treatment initiatives for Cuban Americans in particular could be further explored and enhanced. This chapter explores working with Cuban Americans and treating dementia in the context of their cultural orientation. The chapter begins with a discussion of periods of migration from Cuba to the U.S. and their resulting geographical concentrations. Sociocultural factors are then introduced and related to Cuban American elders and the traditional Cuban family. Cuban caregivers in the context of Hispanic caregivers are discussed in depth and the following general areas are covered: intervention strategies and Cuban caregivers of dementia patients; religiosity or spirituality within the Cuban community and its role in mental health; end-of-life issues; and finally, resources for Cuban families & other practical suggestions for those who work with Cuban families and their aging family members are provided.

"Alzheimer's disease and communities of color"

Allery, A.J., Aranda, M.P., Dilworth-Anderson, P., Guerrero, M., Hann, M.N., Hendrie, H., Hinton, L., Iris, M.A., Jackson, J.S., Jervis, L.L., Lampley-Dallas, V., Manly, J.J., Radebauth, T.S., Robinson, J.W., Tang, P., Valle, R., & White, L. (2004). In: K. Whitfield (Ed.), Closing the gap: Improving the health of minority elders in the new millennium. Washington, DC: Gerontological Society of America, pp. 81–86.

"Cognitive behavioral case management for depressed low-income older adults"

Areán, P.A., Alexopoulos, G., & Chu, J.P. (2008). In D. Gallagher-Thompson, A.M. Steffen, & L.W. Thompson (Eds.), Handbook of behavioral and cognitive therapies with older adults, (pp. 219-232). New York, NY: Springer Science + Business Media. doi: 10.1007/978-0-387-72007-4_14 

The purpose of this chapter is to introduce the reader to cognitive behavioral case management (CB case management) for low-income elderly patients. This intervention was developed at San Francisco General Hospital and has been researched by the Over-60 Team at UCSF. CB case management arose out of the recognition that older adults living in financial distress often have difficulty utilizing the important therapeutic strategies that are present in CBT. It also arose out of the fact that income status appears to be an important factor in treatment outcomes for late-life depression; older adults living in poverty appear to have poor and unstable response to antidepressant medication and other psychotherapies, such as interpersonal therapy. In addition, the clients of the present authors report that while they valued the utility of depression interventions such as CBT, the interventions themselves did not address complex and urgent social problems that the clients were at a loss to manage themselves; in essence, they needed another person's help to negotiate the complex social service system to have their needs met. The team at UCSF piloted the combination of CBT and clinical case management in treating major depression in low-income elderly, and found that the combination of these two interventions was more powerful in alleviating depression than the two interventions on their own. This chapter discusses the prevalence of poverty in late life, the consequences of poverty in an aging population, and the rationale and process by which CB case management alleviates depression.

"The cultural context of clinical work with aging caregivers"

Crowther, M., & Austin, A. (2009). In S.H. Qualls & S.H. Zarit (Eds.), Aging families and caregiving . Wiley series in clinical geropsychology., (pp. 45-60). Hoboken, NJ: John Wiley & Sons Inc. 

This chapter reviews effects of culture on family caregiving. Changes in the ethnic profile of older adults may impact caregiving in a variety of ways, including service utilization and delivery, attitudes, beliefs, values, social support and expression of mental and physical health symptoms. The number of older ethnic minorities in the United States is increasing and will continue to grow well into this century. Given this demographic shift, it is imperative that our understanding of the experiences and needs of aging caregivers be considered in the context of the caregivers' culture. A caregiver's cultural perspective — which may include particular views about physical and mental illness, the role of family and spiritual or religious beliefs — may influence the caregiver's perceptions of and reactions to the caregiving role, utilization of support services and other aspects of the caregiving experience. Consideration of the cultural context of caregiving can assist health-care professionals in understanding diverse caregiving patterns as well as health and service needs. To effectively incorporate cultural considerations into our clinical practice, we must go beyond the hierarchical model of health care in working with ethnic minority caregivers.

"The social and cultural context of psychotherapy with older adults"

Crowther, M.R., Shurgot, G.R., Perkins, M., & Rodriquez, R. (2006). In S.H. Qualls & B.G. Knight (Eds.), Psychotherapy for depression in older adults. Wiley series in clinical geropsychology (pp. 179-199). Hoboken, NJ: John Wiley & Sons, Inc. 

The population of the United States is growing older and becoming more ethnically diverse. According to Census Bureau projections, the number of persons age 65 and older will increase from 35 million in the year 2000, to 66 million by 2030, and to 82 million by 2050, a figure accounting for 20.3 percent of the entire population. This "gerontological explosion" will also occur across groups of minority elders, whose respective population sizes will nearly double by 2050. These two demographic trends highlight the increasing diversity of our aging population, a group that defies simple characterization by encompassing divergent historical, social and cultural experiences. Several recent reports also denote the importance of race, ethnicity and culture in mental health research and practice, including Mental Health: Culture, Race, and Ethnicity — A Supplement to Mental Health: A Report of the Surgeon General , the American Psychological Association's "Guidelines for Psychological Practice with Older Adults," and APA's "Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists." Hence, the challenge for geropsychologists lies in exploring and considering the diverse sociocultural context of older adults in their clinical work, which includes issues of ethnicity, culture, gender, income/education, rural settings, sexual orientation and disability. This chapter provides an overview of the diverse sociocultural context of psychotherapy with older adults, some general considerations when conducting clinical work with diverse elders, and recommendations for future readings. Given the need to cover such a broad array of sociocultural topics, we have divided the chapter into two sections. The first section focuses on ethnic minority elders and the second addresses other populations that should be considered when addressing the social and cultural context of psychotherapy with older adults.

"The family as the unit of assessment and treatment in work with ethnically diverse older adults with dementia"

Gallagher-Thompson, D. (2006). In G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity and the dementias (2 nd ed., pp. 119-124). New York, NY: Routledge/Taylor & Francis Group. 

Why focus on the family (broadly defined) when working with elders from ethnically diverse backgrounds? In other words, clinicians may ask themselves the following: why bother to learn new information and develop the skills needed to work with ethnically diverse families? One concrete reason focuses on medical decision making; for instance, in situations in which clinicians believe it may be time to place the person with dementia in a nursing home or some other institutional setting, they may soon find that the process is stalled, and action is not taken. In the case of Hispanic/Latino and Chinese families, for example, key members of the family may live in Mexico, Cuba, Taiwan, Hong Kong or mainland China. They often cannot be physically present at an appointment to discuss such matters, but they are consulted before any important decisions are made. Clinicians who are not aware of this practice may alienate the family by trying to rush a decision before family members are ready, or may seem disrespectful and unaware of how traditional family roles operate in most non-Caucasian cultures. We argue in this brief chapter that inclusion of the family (broadly defined) is crucial to success — it is not really an option in this time of significant health disparities. Most ethnically diverse individuals prefer to be treated within their family unit rather than solely as individuals; it is likely that greater appreciation of this fact, and accommodation to it in the health-care visit, will result in the reduction of at least some of the barriers that lead to disparities in health-care access.

"Epidemiology, assessment and treatment of depression in older Latinos"

Hinton, L., & Areán , P.A. (2008). In S.A. Aguilar-Gaxiola & T.P. Gullotta (Eds.), Depression in Latinos: Assessment, treatment, and prevention . Issues in children's and families' lives (pp. 277-298). New York, NY: Springer Science + Business Media. 

Dramatic increases in the size of the elderly Latino population projected for this century underscore the need to better understand the mental health needs of this population, and how they differ not only from other ethnic groups but also how they differ between elderly and nonelderly Latinos. This chapter reviews the current literature on the epidemiology, assessment and treatment of depression among older Latinos in the United States.

"Gerodiversity and social justice: Voices of minority elders"

Iwasaki, M., Tazeau, Y.N., Kimmel, D., Baker, N.L., McCallum, T.J. (2009). In J.L. Chin (Ed.), Diversity in Mind and in Action: Vol. 3. Social justice matters. Praeger perspectives: Race and ethnicity in psychology, (pp. 71-90). Santa Barbara, CA, US: Praeger/ABC-CLIO, xviii, 226 pp. 

Age may be a matter of chronology and biology, but aging is a culturally contextualized experience.  The face of American elders in the future will be more multifaceted in terms of race, ethnicity, sexual orientation, religion and disability status and their intersections. Minority status such as race, ethnicity, gender, age, sexual orientation, social-economic levels, religion and disability are often studied and addressed in piece-meal fashion. In that process, psychologists have accumulated considerable information from valuable empirically-based research that has focused on one culture or issue at a time. These cultural factors, however, do not exist as isolated influences and incidences. Instead, they intersect with all the other threads that make up the tapestry of human existence. Although the process of aging and issues related to aging are relevant to all individuals, aging is often overlooked when studying ethnic diversity or is discussed in terms of a separate minority status. The meaning of growing older is framed by culture. Both the meaning of aging and the experience of aging is shaped by one's culture and by the relationship of that culture to the dominant paradigms and practices of the society or nation in which one resides. Aging-related issues may present particular challenges and additional hardships to minority communities; they may also involve special meanings and opportunities to grow. The present status of older adults within a cultural group in the United States represents the rich and complex cumulative effect of one's life experience as a minority individual either born in the United States or emigrated from another country.  

"A cultural lens on biopsychosocial models of aging"

Jackson, J.S., Antonucci, T., & Brown, E. (2004). In P.T. Costa, Jr., & I.C. Siegler (Eds.), Recent advances in psychology and aging, 221-242. New York: Elsevier. 

In this chapter a reconceptualization of the biopsychosocial model is proposed to emphasize the role of culture in the aging process. Although the psychosocial components of the biopsychosocial model can be construed to incorporate the concept of culture, the changing times and demographics highlight the ways in which culture pervasively and uniquely influences aging. The chapter begins with a consideration of the basic biopsychosocial model as originally proposed, suggesting that there is an urgent need to include a life span developmental, as well as a cultural perspective informed by increasingly better quality empirical evidence. A consideration of current findings with a special emphasis on racial and ethnic minority groups follows. In this chapter, using current thinking with respect to the biopsychosocial model, the authors consider how culture, in both majority and minority groups, informs our knowledge and understanding of social relations and health. Prior thinking about the role of biology in social relations and health and provide examples of the documented influence of culture is reviewed; and how this approach might serve to account for findings that had previously been interpreted as either controversial or illogical is considered. The authors propose that the application of a biopsychosocially informed ethnic research matrix might advance research and public policy of ethnic and racial differences in aging related processes.

"Discrimination, chronic stress, and mortality among Black Americans: A life course framework"

Jackson, J.S., Hudson, D., Kershaw, K., Mezuk, B., Rafferty, J., & Tuttle, K.K. (2011). In R.G. Rogers, & E.M. Crimmins (Eds.), International Handbook of Adult Mortality(2), 311-328 doi: 10.1007/978-90-481-9996-9_15 

A life course framework is used to analyze lifetime patterns of mortality among black Americans. Using this framework directs attention to specific questions regarding the potential causes of racial group differentials in mortality, and we hope moves the field toward more comprehensive and testable explanations. The work on aging, the life course and health has long highlighted the racial crossover effect in late-life mortality (e.g., Johnson 2000). While there are heated debates about the causes of this racial crossover in the United States (e.g., Johnson 2000; Preston et al. 1996), demographers have noted its existence in both cross-sectional population-level data, and in longitudinal panel studies (Johnson 2000). Gibson (Gibson 1991, 1994; Gibson and Jackson 1987) speculated that the racial crossover is based upon a series of mortality sweeps beginning in the black population in midlife, thereby leaving a hardier group of blacks in very older ages whose probability of survival in comparison to whites' reverses and becomes more favorable.

"Historical context for research on lesbian, gay, bisexual, and transgender aging"

Kimmel, D., Rose, T., Orel, N., & Green, B. (2006). In D. Kimmel, T. Rose, & S. David (Eds.), Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives (pp. 2-19). NY: Columbia University Press. 

This chapter presents an introduction to the historical context of lesbian, gay, bisexual and transgendered (LGBT) aging research and clinical practice. In three decades, the multidisciplinary field of LGBT gerontology has moved from the hidden recesses of secret support groups into the full range of activities and services. The authors discuss early research in the 1970s and the developing consciousness of LGBT aging, which included relations with families, bisexual aging, and multicultural issues. Other topics discussed include ageism and heterosexism, the impact of heterosexism on programs and services for LGBT elders, and the impact of ageism on the LGBT community. The authors also address the marginalization of LGBT elders through a continuum of affirming services.

"Individual and cultural diversity considerations in geropsychology"

Tazeau, Y. (2011). In V. Molinari (Ed.), Specialty Competencies in Geropsychology (pp. 103-114). NY: Oxford University Press. 

Americans age 65 and over now number approximately 35 million in the United States, of whom 7 million are ethnic/racial minorities (U.S. Census Bureau, 2007). These same demographic trends predict increased growth rates for minority elders as compared to White older Americans (Administration on Aging, 2008). Although these figures highlight the increasing ethnic and racial diversity among older Americans, diversity is a broader concept when considered at the individual and cultural levels. Diversity encompasses ethnicity and race as well as age, gender, income, education, location of residence, national origin (U.S. born, foreign-born, immigrant status), language, family composition, disability (physical, cognitive, emotional), religion/spirituality and sexual orientation. Expanding our conceptualization of geropsychology to encompass diversity as a foundational competence provides for the ability to meet the needs of today's changing demographic, of committing the profession to social responsibility, and of ensuring that core practices of assessment, intervention, and consultation will remain innovative and relevant for the needs of older adults.  

"Clinical intervention with ethnic minority elders"

Tsai, J. L., & Carstensen, L. L. (1996). In L.L. Carstensen, B. Edelstein, & L. Dornbrand (Eds.), The Practical Handbook of Clinical Gerontology (pp. 76-106). Thousand Oaks, CA: Sage Publications. 

In this chapter, clinical recommendations regarding the treatment of ethnic minority populations are proposed. The influence of how differences across ethnic minority groups (e.g., their historical experiences in the U.S.) may come to influence the experience of old age and what implications these differences may have for clinical work with ethnic minority elders are discussed. Possible sources of within-group variation (e.g., acculturation, place of residence, role of ethnicity) that have received minimal attention in the existing literature are also noted. Focusing on various Asian-American, African-American, Hispanic American, and Native American populations, it is shown that the backgrounds and the issues these subgroups face may be as different from one another as from mainstream European Americans, attesting to the dubiousness of considering minority elders as one group. An overview is provided of the cultural, political and social circumstances that brought these peoples to the U.S., factors that continue to influence the current needs and values of different subgroups and that may influence the type of problems individuals present in mental health and medical settings. The influence that ethnicity may have on the experience of old age as well as aspects of the therapeutic process discussed and special problems that arise in working with older members of ethnic minority groups in the US, are highlighted along with possible solutions.

"Health disparities, social class and aging"

Whitfield, K. E., Thorpe, R. & Szanton, K. S. (2011). In K. W. Schaie & S. Willis (Eds.), Handbook of the Psychology of Aging (7 th ed., pp. 207-218). Burlington, MA: Elsevier Academic Press. doi:10.1016/B978-0-12-380882-0.00013-9 

The goal of this chapter is to provide an overview of the issues related to how health, social class and aging intersect to create important patterns. These patterns are important for social scientists to understand aging as well as for policy makers to identify areas of opportunity for interventions. This chapter developed from an interdisciplinary perspective. First, socioeconomic and health status are reviewed, then how they work in concert to contribute to the disparities observed in later life was examined. Suggestions for future directions based on the current knowledge and advances in technologies are also provided.

"Asian American and Pacific Islander Families: Resiliency and life-span socialization in a cultural context"

Yee, B.W.K, DeBaryshe, B.D., Yuen, S., Kim, S.Y., & McCubbin, H. (2007). In. F.T.L. Leong, A. Ebreo, L. Kinoshita, A.G. Inman, L.H. Yang, & M. Fu, (Eds.), Handbook of Asian American psychology (2nd ed., pp. 69-86). Thousand Oaks, CA: Sage Publications, Inc. 

Asian-American and Pacific Islanders (AAPIs) are often portrayed as a resilient "model minority." AAPI individuals have been described as being well educated and financially stable; valuing hard work and family ties; and exhibiting positive social behaviors. This positive characterization overlooks the difficult life circumstances that some AAPI individuals experience and downplays the very real needs of those who are vulnerable to experiences of discrimination, trauma or poverty. An examination of the evidence reveals great variation in the prevalence of risk and protective factors and resiliency processes across AAPI ethnic groups (Yee, Huang & Lew, 1998). In this chapter, the authors highlight how AAPI families provide protection and diminish risk for family members as they traverse developmental milestones and cope with challenges over the life course. Specifically, the authors (a) provide a family resilience conceptual framework for understanding risk and protective factors in AAPI families, (b) discuss how AAPI cultures promote family interdependence as a basis for family protective or risk factors, (c) outline key demographic variables that serve as risk and protective factors for AAPI families, (d) address family life-cycle issues for AAPI families and (e) conclude by highlighting directions for future AAPI family research opportunities and federal family research funding policies.

• National Caucus and Center on the Black Aged 
  
  
• National Hispanic Council on Aging 
  
  
• National Indian Council on Aging 
  
  
• National Pacific/Asian Resource Center on Aging 
  
  
• NIHSeniorHealth
  An easy-to-use website from the National Institutes of Health that features health and wellness information for older adults. 
  
  
• Older Americans Behavioral Health Issue Brief 11: Reaching Diverse Older Adult Populations and Engaging Them in Prevention Services and Early Interventions (PDF, 1MB)
  This Issue Brief describes the prevalence of behavioral health problems in diverse groups of older adults; identifies strategies for reaching and engaging older adults in behavioral health services; and offers examples of behavioral health programs that have successfully engaged diverse groups of older adults, including African-American, American Indian/Alaska Native (AI/AN), Asian-American, and Hispanic/Latino older adults; lesbian, gay, bisexual and transgender older populations; and older adults living in rural areas. 
  
  
• SAGE National Resource Center on LGBT Aging
  Established in 2010, the National Resource Center on LGBT Aging provides training, technical assistance, and educational resources to aging providers, LGBT organizations and LGBT older adults. 
  
  
• Stanford University, Older Adult and Family Center 
  Information about evidence-based caregiver intervention programs conducted with ethnically, culturally and linguistically diverse older adults; and specific dementia-caregiving related materials in multiple languages are provided. 
  
  
• Transforming Mental Health Services for Older People: Lesbian, Gay, Bisexual and Transgender Challenges and Opportunities
  FORGE: Transgender Aging Network. FORGE to provides peer support primarily to those on the female-to-male gender spectrum and local Significant Others, Friends, Family, and Allies (SOFFAs). 
  
  
• What is a Healthy Brain? New Research Explores Perceptions of Cognitive Health Among Diverse Older Adults (PDF, 1.3MB)
  Centers for Disease Control and Prevention