Introduction

The Japanese society continues to age rapidly. In 2022, the proportion of people aged 65 years and above was 29.1%, which is the highest worldwide. By the year 2050, this number is estimated to increase to approximately 40% [1]. Because dementia is often associated with psychiatric symptoms [2] and disorders [3], differential diagnosis remains a challenge among clinicians. However, no studies on the prevalence of psychiatric disorders among the older Japanese population have been conducted, thereby suggesting methodological difficulties and/or low public concern.

Mental health challenges are significant among older individuals. In 1999, Jeste et al. presented a consensus statement [4] in which they predicted that 20% of older individuals would experience mental health challenges. Furthermore, according to Age Concern England [5], 6% of older people in the UK are predicted to experience mental health challenges. Moreover, in 2015, a large epidemiological study conducted in the USA [6] reported that 11.4%, 6.8%, 3.8%, and 14.5% of older individuals experienced anxiety, depressive, addiction, and personality disorders, respectively, in the past year. Similarly, in 2017, a large study conducted in Europe [7] reported that 23% of older individuals had mental disorders.

Specific models of care have been proposed and implemented throughout the society to address mental health challenges among older people [8]. For affective disorders, the collaborative care model is reported to be feasible and significantly more effective than the usual care model [9]. This model comprises four components: 1) a multi-professional approach to patient care, 2) a structured management plan tailored to the individual needs of the patient, 3) proactive follow-up aimed at delivering evidence-based treatments, and 4) processes for enhancing inter-professional communication, such as routine and regular team meetings and/or shared records [10]. Additionally, older persons suffering from schizophrenia have higher frequency and severity levels of physical diseases, and yet, they receive significantly less than adequate health care [11]. The combination of psychosocial-skill training with preventive healthcare intervention is reported to have positive effects [25]. We decided to conduct interviews via an interdisciplinary team comprising a psychiatrist (TO, male, 40’s, working as the director of the public medical research institute, and also working as a clinician for 1–2 days a week), a public health nurse from a non-profit organization supporting homeless individuals (MY, female, 40’s, working as the board member of a support group for homeless individuals while directing the health issues of the users), and a Buddhist priest as well as social researcher (TA, male, 30’s, a Buddhist priest belonging to the Jodo denomination, which is one of the main seven denominations in Japanese Buddhism and is also a university lecturer) to cover the comprehensive needs of older people, as well as their physical, psychosocial, and spiritual needs (Fig. 2).

Fig. 2
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Formation of an interdisciplinary team to cover the comprehensive needs of older people

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Basic characteristics, such as age and certifications, were enquired, followed by whether the interviewees had cases of middle-aged and older people with urgent, unaware, and unmet mental health care needs. If the answer was yes, we asked them to describe the details.

We asked the interviewees to talk freely and avoid blocking out information. All the diagnoses were enquired throughout the course of the interviews. Therefore, they were of a wide variety, including those in formal statistical manuals for addressing simple behavioral conditions. We did not confirm whether the diagnoses were made by medical professionals or specialists. In other words, the diagnoses depended on the interviewees’ stories. We included middle-aged people as the topic of the interview. This was because 1) middle-aged people and older people were in continuity, and 2) the interviewees supported middle-aged people around older people.

The interviews were conducted in private rooms or online to avoid being overheard by third parties. All the proper names were initialed when the verbatim transcripts were digitized. The interviewees were assigned an ID number, and a separate comparison chart was maintained.　Written informed consent was obtained from all the participants prior to the interviews.

Analysis

All the interviews were conducted in Japanese and audio recorded, after which they were transcribed verbatim. Field notes were also prepared during the interviews. We adopted a qualitative descriptive approach [26]. Qualitative description was useful in previous exploratory studies with limited knowledge regarding the topic. The interviews conducted in this study were guided by case presentations because the interviewees were practitioners. Accordingly, the analysis of the data collected comprised two steps. First, we created a summary of each case. Next, we explored the factors related to the non-utilization of formal mental health care systems among older people with urgent, unaware, and unmet mental health care needs. Following the principles of qualitative description methodologies, we conducted a thematic analysis to identify the themes in the data and establish meaningful categories. We allowed the interviewees to talk beyond a specific case, i.e., their general opinions. This information was also considered valuable data. The text fragments were coded using MAXQDA 2018®. Constant comparisons were conducted, and all the authors had access to all the data. Additionally, everything concerning the study was decided in research meetings. All the analyses were conducted in Japanese. After the manuscript was prepared in Japanese, it was translated into English by the authors and a native English-speaker. All the authors agreed that the English version retained the meaning of the analyses.

Results

Cases discussed

A summary of the 32 cases involved in this study is presented in Table 2. The number of cases discussed by each interviewee was two to six, with an average of 3.6. The 32 cases included one couple and one pair of sisters, i.e., 34 persons (16 females and 18 males). Concerning age, the number of cases per age group were seven (40’s), three (50’s), four (60’s), eight (70’s), and 10 (80’s), and the remaining two were just “old” sisters. The suspected diagnoses showed wide diversity, and the most frequent category was “unspecified,” (seven cases) followed by “schizophrenia,” (six cases) “dementia,” (five cases), “suicide attempts” (three cases), and “depression” (two cases), which overlapped.

Table 2 Summary of the cases
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Figure 3 illustrates the outcomes of the cases. A total of 11 cases moved into the mental health care system: seven in outpatient clinics and four hospitalized. Eight cases moved into community care, outside the mental health care system. Furthermore, 10 cases were referred to no service usage, and three were ongoing.

Fig. 3
figure 3

Overview of the outcomes of the cases involved in this study. Note: × stands for the outcome that resulted in no service usage. 11 cases were moved into the mental health care system (downward arrows), seven cases involved outpatient care, and four cases involved inpatient care; eight cases involved social care (upward arrows); 10 cases involved no service usage ( ×); and the remaining three were ongoing cases

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Factors related to the non-utilization of formal mental health care systems

Concerning the factors related to the non-utilization of formal mental health care systems for the older people with urgent, unaware, and unmet mental health care needs, despite the existence of UHC, two over-arching categories emerged: “factors related to an individual person” and “factors related to the systems.” The categories included “individual intrinsic factors” and “family factors” for the former, and “physical health system related factors,” “mental health system-related factors,” “social service system related-factors,” and the “lack of integration between systems” for the latter. Some themes, such as “community people-related factors” and “factors related to inter-regional movement,” were not considered over-arching factors. The arrangements of the over-arching categories, factors, and sub-factors are listed in Table 3.

Table 3 Arrangements of the over-arching categories, factors, and sub-factors
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Factors related to a specific individual (over-arching category)

Individual intrinsic factors

Some cases involved the difficulty in receiving support from others, and as a result, they were named “difficulty in seeking help.”

She has been working for some time, but she never disclosed such details to the supporters. Because she never let the supporters in her house, nobody could support her throughout her daily life. The supporters had to communicate with her on a park bench. She then filed a complaint with the administrative grievance office, saying that she was repeatedly told to let the supporters into her home (Interviewee No 6; on case 23).

Cases involving “delusions” were expressed as significantly difficult cases by several interviewees, as follows:

We have many cases involving delusions, and all of them are not connected to medical systems (Interviewee No 2; not on a specific case).

Individuals with delusions are difficult to support. In cases where hospitalization is driven by complaining neighbors, it is far more difficult to provide support for such individuals. Such patients no longer have delusions after hospitalization because of the change in environment. The sources of the delusions cannot be determined in the hospital environment. However, soon after discharge from the hospital, the delusions reappear (Interviewee No 9; not on a specific case) [Explanatory note: neighbors do not have the power to force people to get admitted to a hospital. However, they might have an influence on the proxy].

Family factor

“Discord between family members” was reported to be a crucial factor.

The client’s family who live together and the client’s parents who live in a different household were not aligned at all (Interviewee No 9; on case 31).

In cases where the family denied engagement, the case work sometimes stopped. This was named “denial to engage.”

There is a family in the distant region. However, they said that they could not do anything in case the hospital staff tried to make contact (Interviewee No 8; on case 29).

According to the interviewees, “multiple cases in one family” made the situation significantly complex.

The mother has dementia, the older son has schizophrenia, and the younger son has undiagnosed intellectual disabilities. After the father died, everything went wrong (Interviewee No 3; on cases 15 and 16).

In addition to the client’s difficulty in seeking help, as described above, the “family's difficulty in seeking help” was also discussed.

It is difficult to provide support if the husband is attempting to deal with the wife’s problem alone, and if the husband is older but still working, it is difficult for him to entrust his wife to someone else (Interviewee No 1; not on a specific case).

Factors related to the systems (over-arching category)

Physical health system-related factors

In the physical health setting, people providing professional care to individuals suffering from mental illnesses were not well-equipped. Staff members without enough skills or knowledge were regarded as those in the “indifference of the physical health care provider regarding mental health matters” category.

In general hospitals, people suffering from mental illnesses are sometimes regarded as troublemakers and are talked about in the contexts of the ways in which to quickly discharge them (Interviewee No 8; not on a specific case).

Some people were out of the medical health care system, and they were placed in the category of “discontinuation of physical health conditions.”

The problem was that he had infections resulting from the human immunodeficiency virus and the hepatitis B virus. However, he stopped seeing doctors (No 7; on one episode).

Mental health system-related factors

Furthermore, the issue of “irresponsive mental health care systems” was also discussed.

A person who was just discharged from a psychiatric hospital got worse again. When we asked the hospital about further inpatient care, they said that they cannot apply to the health insurance provider for the payment of additional acute care within three months after the previous discharge (Interviewee No 3; not on a specific case) [Explanatory note: In the end, the patient was accepted by the hospital].

(Despite the imminent violence against his wife and the destruction of his television using a hammer, after the arrival of the police, he was not admitted to the psychiatric emergency system by the authority because they said no one was injured during the incident　[Interviewee No 3; on case 13]).

Some clients had “uncomfortable experiences in their previous visits to clinics.”

We once went to a psychiatric clinic together, but he did not get along with the doctor, and he fell into a state of medical mistrust, saying that he would never go back (Interviewee No 7; on case 26).

Social service system-related factors

Some of the staff members did not have enough time to support people suffering from mental health challenges, and this category was named as “lack of time to provide care.”

In our work settings, we cannot repeat interviews like psychologists. If we communicate intensively for a long time, the patients might start talking about previous traumatic experiences (Interviewee No 1; not on a specific case).

The limitations of social welfare systems were also discussed, especially as they pertained to cases without rigid diagnosis, and this category was named “social service was not allowed without diagnosis.”

In short, if one is not eligible for drug therapy, clinics will not readily accept them (Interviewee No 4).

You cannot use social welfare support because you do not have a disability (Interviewee No 5).

Sometimes they found “no appropriate service in the community.”

Concerning individuals with developmental disabilities, medical staff remained negative. Public health nurses said that they cannot deal with such individuals. The staff of the center for developmental disorders said that the services can commence only after the person comes to the center (Interviewee No 3; on case 16).

Lack of integration between the systems

The lack of integration between the systems was repeatedly mentioned.

They say, “We can only help you so far.” With an increase in the number of various systems, the subject falls between the cracks (Interviewee No 3; not on a specific case).

We should work based on the idea of the ways in which we can solve the problems in front of us, and we should not work within the job description given to us (Interviewee No 5; not on a specific case).

There are many different parties involved, but each party is working on a single problem of the client. Therefore, information is not being shared between the parties involved (Interviewee No 6; not on a specific case).

Others (outside the over-arching categories)

Community people-related factors

In addition to the individual and system factors, community people played a significant role in ensuring social inclusion.

Until then, people in the community had been hel** them in various ways. However, with the introduction of long-term care insurance services, local people are becoming increasingly reserved or at ease, and as a result, they are no longer involved. Until then, people in the community helped such individuals, but currently, they find themselves in situations where the only people around them are professionals (Interviewee No 3; not on a specific case).

Factors related to inter-regional movement

As per clinical knowledge, it was reported that the moment of just having moved to another area was a crucial moment.

As for those who have recently moved to the area, the names of their previous residences are personal information, and we do not have any knowledge of such information. We can only ask the patient. We are not allowed to collect information about such individuals unless they are a nuisance or otherwise, significantly serious. Therefore, we do not know anything about someone who has just moved into the area (Interviewee No 1; not on a specific case).

Discussion

This study explored the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs, despite the existence of UHC. As per the results, two over-arching categories emerged, i.e., “factors related to an individual” and “factors related to systems,” which suggested certain targets for intervention, as discussed below. In addition to the factors under these categories, “inter-regional movement” and “community people-related factors” also emerged in this study.

Individual intrinsic factors involved the “difficulty in seeking help” and “delusional disorders,” consistent with previous literature as well as our clinical experiences. Concerning the difficulty in seeking help, the low rates of professional mental health service usage among older people has been reported in previous studies [27]. Whether this underuse results from the negative attitudes toward seeking help remains controversial. Mackenzie et al. [28] reported that 80% of older people showed positive attitudes towards seeking help, and they concluded that providing resources, such as the access to properly trained geriatric mental health professionals, was necessary. From Japan, Murata reported that the realistic factors related to delayed care were cost, distance, transportation problems, and conditions not serious enough to require seeking help [29]. The recognition of the ways in which older people may inadequately understand their health or be unaware of available services has also been suggested [30]. Concerning another factor, i.e., delusional disorders, according to Lapid and Ho [31], older people suffering from delusional disorders did not seek help and were often undiagnosed and untreated. From a conventional view, little can be done for people suffering from delusional disorders. However, Nagendra et al. [32] reported a high recovery rate of delusional disorders among older people. This suggests that the initiation of therapy through mental health competence, such as building a therapeutic alliance, is the key to addressing such issues. Recently, a Japanese group reported a successful case involving an elderly woman with lifetime undiagnosed delusion. By welcoming her to the community space and not referring her immediately, and by taking enough time to build trust with each other, she eventually saw a psychiatrist and very little medication significantly improved her general health [33].

The family factor, specifically, that involving “multiple cases in one family,” was a phenomenon sometimes faced by the clinicians. In biological psychiatry, a multiplex family has been a major concern because it is the key to establishing the crucial gene behind the disease. As an extension of this context, the burden of care was reported to be highly significant for families with more than one ill member (multiplex) compared to families with a single affected individual (simplex) [34]. Contrarily, what we encountered in this study was not associated with genetic multiplexity. One family comprised individuals suffering from dementia, schizophrenia, and developmental disorders, whereas another comprised a married couple suffering from schizophrenia and ADHD. The results of this study suggested that the provision of particularly intensive care for families with multiple cases was inherent. The “denial for engagement” factor was also reported by Sung-Wan Kim et al. [35]. They suggested ensuring intensive efforts and early involvement after contact with health care services. As far as we searched, although it is evident that “discord between family members” affects the treatment of mental health problems form the clinical perspective, the evidence provided in this study is not enough. In the field of palliative care, family discord is reported to relate to stronger preferences for life-prolonging treatments and weaker preferences for palliative care [36]. Concerning the “family’s attitude toward seeking help,” the associated literature is also sparse. Mc Gonagh explored the factor of family’s attitude among adolescents suffering from anxiety disorders, and they reported that the family’s attitude affected the patients’ attitudes [37]. These findings suggest that this pattern may be similar for family relationships among older people with mental health care needs.

This study suggests the improvement of both the physical and mental health systems. In this study, concerning physical health systems, the indifference of medical health staff regarding the provision of care to people with mental health care needs emerged. Wu et al. [38] conducted a mental health literacy survey involving non-mental health professionals in general hospitals throughout China, and they established that the beliefs that non-mental health professionals held regarding mental disorders were inadequate for ensuring the provision of appropriate help. Additionally, previous studies show that people with psychosis have low levels of physical health literacy [39]. There are challenges for both providers and users, as they pertain to the appropriate delivery of physical health care to people with mental health care needs. Wu et al. [38] suggested the implementation of mental health education campaigns to enhance mental health knowledge among non-mental health professionals.

Concerning mental health care systems, the “irresponsive mental health care system” factor was merged in this study. Mental health care systems should ensure increased responsibility, especially regarding emergency inpatient care. Regarding the provision of social services, the lack of human resources, the excessive need for medical diagnoses, and the narrowness of the prepared services were discussed in this study. In this study, we advocated for the expansion of social services, as they pertain to human resources, the flexibility of use, and the breadth of the types of care provided. Additionally, “uncomfortable experiences in previous visits to clinicians” were noted in this study. Previous studies show that older people experience being treated differently as a result of ageism [40] or not being listened to fully from the beginning of the treatment of their mental illnesses [41]. A new finding, “just moved to a new region,” was a decisive factor. Community ties continue to weaken, especially in urban areas. As long as informed consent was obtained, visits by mental health professionals to people who had just moved to the region was one method for strengthening social support networks among communities and including older people at the potential risk of mental disorders.

In this study, we also suggested that social service systems are not responsive to older people with mental health care needs because 1) the staff do not have enough time, 2) the staff cannot respond freely without diagnoses, 3) and no appropriate service menus are prepared when the older people with urgent, unaware, and unmet mental health care needs contact social services. To the best of our knowledge, there are no studies investigating this issue. From the limited data obtained in this study, we suggest the expansion of social services, as they pertain to human resources, the flexibility of use, and the breadth of the types of care provided.

Concerning the “lack of integration between the systems,” the Ministry of Health, Labor, and Welfare of Japan points out that vertically segmented administrative systems present a point of weakness in Japan’s social security system [42]. This is an institutional problem that is too large to be the subject of research, and no empirical studies pertinent to clinical practice could be found. However, the phenomenon of older people with urgent, unaware, and unmet mental health care needs remains a satisfactory guide for future institutional design in that it clearly demonstrates the existence of this problem. In this study, the “community people-related factor” specifically involved the lack of continuity in the involvement of care among community residents. This is another way of stating the lack of integration between various social security systems and the communities involved.

No overt spiritual needs were discussed in this study. However, this was because we only interviewed professionals and not individuals. Therefore, it is natural that the objectively assessed medical and social needs were discussed first. In our previous study, we reported the possibility that medical professionals disclosed their suffering only in the presence of a priest [43].

Conclusions

In this study, the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs, despite the existence of UHC, were categorized, and they suggested the requirement of a specific target for intervention. The interventions discussed in this study are listed in Table 3. Concerning the individual intrinsic factors, for the factor associated with difficulty in seeking help, we suggested the public and professional recognition of the ways in which older people may inadequately understand their health or be unaware of the services available. Regarding the factor of delusions, we suggested the formulation and implementation of a therapeutic alliance. Regarding the family factor, we suggested the provision of particularly intensive care for families with family discord, families with multiple cases, and families facing difficulties in seeking help. To facilitate family engagement, intensive efforts and early involvement after achieving contact with mental health care services are necessary. Concerning the physical health system-related factor, mental health education campaigns aimed at enhancing mental health knowledge among non-mental health professionals are essential. For the mental health system-related factor, reforms aimed at increasing responsibility levels, especially regarding emergency inpatient care, and promoting listening without ageism in clinical practice are essential. For the social service system-related factor, the expansion of social services regarding human resources, the flexibility of use, and the breadth of the types of care provided are required. Regarding the lack of integration between the systems, facilitating the integration between the systems is necessary, which is Japan’s policy goal, as described above. Regarding the community people-related factor, encouraging community residents to involve themselves in social security systems is necessary, and finally, for the factors related to inter-regional movement, the provision of particularly intensive care for people who have just moved to new areas might be promising. Among such factors, novel and realistic insights explaining the reasons why inter-regional movements are critical among various individuals can be achieved. Accordingly, the interventions provided to older people at the time of movement can be considered variables in future studies on this subject.

Limitations and directions for future research

This study has several limitations. First, the interviewees were selected through snowball sampling, with inclusion criteria. As a result, the interviewees’ representativeness was not robust. Second, we suggested an interdisciplinary interviewer team’s function for unspoken views. However, we cannot compare this with control interviews, such as interviews conducted by psychiatrists alone among the same interviewees. Third, this study comprised interviews involving experts or care providers. The advantage of this study was that the facts were organized, and the viewpoints were fixed. However, there had to be facts and views from the care recipients’ side, which were not discussed in the supporters’ interviews. Interviews involving the latter are required to explore the inner need of individuals and understand the unbiased views of both the supporter and the individual. However, the access to such individuals was not possible after they became people with urgent, unaware, and unmet mental health care needs. In this study, we revealed that inter-regional movement was a critical point. Accordingly, people who moved were candidates of future studies. Therefore, it is feasible to broadly reach out to people in our catchment area who have just moved into the community, build relationships, and investigate the internal struggles of those with mental health needs.