Mental Health and Aging: How Research and Philanthropy Can Help Advance Equity

Our understanding of mental and brain health (American Psychological Association, n.d.-a; n.d.-b) and our capacity to support and promote good outcomes have improved dramatically in recent decades as awareness has increased and treatment options have improved. This progress is still uneven and unequal, however, and significant mental health disparities persist. These disparities are pronounced for older people as a group and particularly for older people in underserved communities and historically disadvantaged racial and ethnic groups.

For example, despite higher perceived stress, Blacks are less likely to have a mental health diagnosis or receive treatment for mental health conditions than Whites are (Taylor, 2020). Older Asian American women have higher rates of suicidal ideations and completions than women from other ethnic and racial groups (Taylor, 2020). Diagnosis of Alzheimer’s disease and other dementias is also rife with disparity. Compared to Whites’, Blacks’ and Hispanics’ incidence of the disease is higher (2x and 1.5x respectively), but their likelihood of receiving a diagnosis is much lower (Alzheimer’s Association, 2020).

Deeper understanding of mental health and wellness among older people of diverse backgrounds is fundamental to their well-being and to the well-being of their families and the clinicians who care for them. Considering this challenge from our own professional vantage points – as a geropsychologist directing the Aging Portfolio for the American Psychological Association (APA), and as the leader of a philanthropy-serving organization for funders investing in aging, Grantmakers In Aging (GIA)¹ – we recognize the need to bring a more inclusive lens to both clinical research and philanthropy, and that we could have greater impact if we more intentionally aligned and expanded our thinking and approaches.

In this commentary, we seek to draw on our shared commitment to healthy aging and on our specific backgrounds and experience to offer some observations and recommendations to harness the assets of the research and philanthropic sectors to drive progress toward mental health equity.

What we know

From important recent and ongoing research, we understand certain key points about the mental and brain health of older adults from diverse and underserved backgrounds.

• Stress, resulting from long-term exposure to systemic racism in its many manifestations, is associated with mental health challenges (Taylor, 2020).

• Inequities are cumulative, such that the disparate conditions of racial and ethnic groups put them at greater risk for mental health difficulties and cognitive impairment over the life course (Taylor, 2020).

• Ageism compounds other forms of discrimination and contributes to social exclusion and mental health challenges (Garrison-Diehn, Rummel, Au, & Scherer, 2022).

• There is a correlation between mental health conditions and cognitive impairment (Novak, Chu, Ali, & Chen, 2020).

Understudied and underserved: how incomplete knowledge contributes to unequal outcomes

What is less clear is which research approaches and care models are most appropriate and effective for mental health prevention, education, and service delivery for diverse populations. Much of the existing research has either understudied older adults of various ethnic and racial groups or incorrectly treated them as a monolithic population. When this occurs, it can be easy to miss or misinterpret their experiences (McDonough, Harrell, Black, Allen, & Parmelee, 2021).

This oversight has implications for philanthropy. For decades, the national allocation of philanthropic dollars dedicated to aging has been estimated at between 1 and 2%. Because of this, those who do fund in the aging space understandably hope to safeguard their investments and maximize impact. Often this causes foundations to take a research-driven approach to grantmaking in hopes of leveraging the evidence base to increase the likelihood that funded programs will succeed.

Many funders require prospective grantees to detail the evidence-based practices they plan to implement in their proposals or limit requests for proposals (RFPs) to specific evidence-based practices predetermined by the funder. However, this can inadvertently perpetuate inequalities in care and funding, in part because it tends to result in repeated funding of the same mainstream, established, and, often, White-led organizations. In a related problem, the body of evidence itself is incomplete, as many evidence-based models have not been tested, modified, or evaluated for their cultural congruence and effectiveness with diverse groups (Agency for Healthcare Research and Quality, 2019).

Given this shortfall in the evidence on optimal mental health care for older adults from understudied and underserved communities, how can we grow our understanding and fill the resource gaps that many communities still face? We see four key opportunities.

1. Recognize and address overly narrow research scopes; adopt research criteria that lower barriers to equitable funding.

Evidence and evaluation will always have an important role to play in research and philanthropy, but the pursuit of health equity now demands a reconsideration of some norms to create greater inclusion.

For instance, in many underserved communities and in some clinical settings, there are “promising practices” that already do an excellent job providing culturally congruent, effective, and sustainable care for older adults’ mental and brain health. But these practices often do not receive the “gold standard” level of study (randomized controlled trials, published peer review, replication of outcomes, etc.), either because they are seen as too small or too new, or less methodologically rigorous, or because they simply are not funded at a level that can support the required program design and evaluation (Matthews & Vinson, 2021). Unfortunately, many effective programs are then seen as ineligible for funding because they lack evidence.

In philanthropic circles, as in research protocols, this thinking is beginning to evolve. Increasingly, there is a view that at least some promising solutions should not be excluded simply because they have not been thoroughly tested. Recognizing gaps and, in some cases, bias in the evidence base, some funders and study designers are beginning to consider multiple types of data, including qualitative research studies, and to contribute to building up the evidence base for programs that can show in other ways that they effectively serve diverse older people.

For example, GIA member the Rita and Alex Hillman Foundation, which supports nursing-driven innovative solutions to health equity, offers the Hillman Emergent Innovation Program – funding specifically intended for early- or pre-evidence models of care. Their rationale: “We recognize that transformative innovation, whether it emerges from community health clinics or major academic research centers, doesn’t spring into the world fully formed with reams of evidence. That’s why we invest in bold ideas at different stages of development.” (The Rita and Alex Hillman Foundation, n.d.).

• (2) Invite new ideas and broaden perspective by creating a more diverse pool of clinicians, researchers, research subjects, and grantmakers.

Better research and better outcomes will require more specific within-group studies and more people of color directing and participating in research.

Major institutions are responding. For instance, the American Psychological Association recently issued three resolutions: an apology to people of color for contributing to racism and systemic inequities (2021b); a plan for advancing health equity in psychology (2021a); and The Role of Psychology and APA in Dismantling Systemic Racism Against People of Color in U.S. (2021c). In that resolution, APA affirmed its intention to, among many other steps, “encourage psychological scientists to conduct and report research within APA journals in a manner that better incorporates samples that are more inclusive of participants of color relevant to their psychological research, as appropriate, to increase the diversity of the samples examined and reported in psychological research.” (2021c).

Philanthropy has a similar need to diversify. Funders from a range of backgrounds can invigorate the sector and optimize investments through their nuanced understanding of the needs and assets of communities.

Grantmakers In Aging is working to build a pathway for diverse talent to get started and advance within philanthropy, launching an Equity in Aging Philanthropy Task Force and offering paid GIA internships for students to gain access to networking and skill-building opportunities, with a focus on outreach to students of color. Metta Fund, a GIA member, recently articulated its intention to “apply a racial equity lens to shift its internal and external practices, policies, and grantmaking investments.” (Meta Fund, n.d.)

Funders are increasingly exploring trust-based philanthropy practices that center grantmaking around communities. The Brooklyn Community Foundation is engaged in participatory grantmaking, in which program officers share decision-making with an Elders Fund Advisory Council, whose members are primarily older community residents of color.

• (3) Don’t assume that “one size fits all.” Instead, test, adapt, and evaluate existing models of care for effectiveness with diverse groups.

The nuances of successful models of mental health care may differ significantly from community to community. Only when we understand what older people in different circumstances want, need, and will accept can we determine the appropriate strategies for prevention, education, and service delivery.

For example, models in which Community Health Workers or spiritual leaders are trained to deliver mental health interventions (such as Psychological First Aid) have been effective in increasing access to care and combating stigma and mistrust, particularly in communities of color (Falgas-Bague et al., 2021; Kangovi et al., 2018).

Co-locating mental health care in settings where older people naturally gather or visit regularly can help increase access and uptake, and there are numerous programs that might serve as models. One example: the Department of Veterans Affairs, which integrates behavioral health care across multiple settings, runs a Primary Care Mental Health Integration model that embeds psychologists in primary care practices, where older adults of color are more likely to receive care (Leung et al., 2019).

Outside the highly coordinated environment of the VA, such innovation can be more complicated, but IMPACT (now known as the Collaborative Care Model) has had success developing and disseminating a model of primary care-based depression treatment for diverse older adults that has been tested in a wide variety of settings, through decades of partnership from GIA members including The John A. Hartford Foundation and Archstone Foundation (AIMS Center, n.d.).

• (4) Partner to translate research for a funding audience Despite the widely shared view that evidence-based interventions are desirable, research may feel inaccessible to funders. Research written for an academic audience may not be easily understood by those outside of academia and may be behind a paywall. A common misconception is that all funders are well-resourced, but three-quarters of GIA’s members are smaller, local, or regional foundations that focus on aging but also cover other issue areas or populations. Program officers often oversee multiple portfolios and may not have time to read up on the latest evidence.

Translating research for a funding audience is one important strategy for disseminating and implementing findings. Philanthropy, in turn, can support more partnerships, providing funding to incentivize dialogue and collaboration to help bring new ideas and experiments to a broader range of settings and populations.

Conclusion

While both disciplines strive for an age-diverse society where older adults can lead healthy, productive, and creative lives, researchers and funders tend to operate in silos. To promote health equity and better mental health in later life, funders must understand research better, use it more deliberately, and not allow gaps or shortfalls in evidence to limit equitable funding for community-based providers and recipients of care.

We believe that a future of closer connection and collaboration between research and philanthropy is realistic, and that better quality of life for older adults in every community will be the outcome.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.