Dr. Kennedy is professor in the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine, and director of the Division of Geriatric Psychiatry at Montefiore Medical Center in the Bronx, New York. Mr. Kover is vice president for Nazi Victim Services at Selfhelp Community Services of New York. Dr. Scalmati is assistant professor and Associate Training Program Director at Montefiore Medical Center at Albert Einstein College of Medicine in New York City.
Disclosure: Dr. Kennedy has received grant support from Forest. Mr. Kover and Dr. Scalmati report no affiliation with or financial interest in any organization thay may pose a conflict of interest.
The authors gratefully acknowledge support from the Association for the Planning and Development of Services for the Aged in Israel and the Caring Commission of the United Jewish Appeal (UJA)-Federation of New York City for the Professional Exchange between New York and Israel, October 18-22, 2009, with special thanks to Lindsay Goldman, Planning Executive Caring Commission, UJA-Federation. The Bronx Holocaust Survivors Program is made possible by a grant from the J.E. and Z.B. Butler Foundation. Additional experience with Holocaust survivors in nursing homes has been made possible by the New York Foundation for Elder Care in Memory of Margaret Tietz.
Please direct all correspondence to: Gary J. Kennedy, MD, Director, Division of Geriatric Psychiatry, Montefiore Medical Center, 111 East 210th St, Bronx, NY 10467; Tel: 718-920-4236; Fax: 718-920-6538;
Jews who survived in Nazi-occupied territory from 1939–1945 are a vanishing cohort. Nonetheless, because of advanced age, past trauma, and fears of stigmatization their increasing needs challenge existing mental health services. Because the number of survivors will shrink to zero within the next two decades, a sense of urgency pervades discussion of their care. Novel social support programs developed for Holocaust survivors show promise as avenues to reduce avoidable disability in late life associated with dementia and other mental illnesses. By drawing attention to these programs and extending their reach, it may be possible to preserve their benefits for a larger population in need beyond the last of the Holocaust survivors. The recent Professional Exchange Program to Israel sponsored by JDC-ESHEL in Israel and the Caring Commission of the United Jewish Appeal-Federation of New York suggests such an extension is possible. This column focuses on only one aspect of the Exchange, the integration of mental health services into social programs serving Holocaust survivors in New York City and Israel.
The development of dementia and depression, the progressive loss of family members and of self reliance, and the possibility of nursing home placement are major threats to many older people. However, given the past circumstances of emotional trauma, physical deprivation, and confinement, these events are especially troublesome to aged Holocaust survivors. Fears of being stigmatized by psychiatric care or forced into nursing home or hospital raise added barriers to the provision of mental health care for these individuals. As a result, specialized psychiatric services which provide expertise in geriatric care as well as experience with Holocaust survivors are a critical need. However, in as much as mental health specialists with training in geriatrics are an exceedingly scarce resource, how might they be deployed to maximize use of their expertise? Incorporating mental health information, consultation, and referral for staff, clients, and their families into existing social programs may maximize the reach of mental health specialists and minimize the stigma of psychiatric services. This is only one inference drawn from the recent Professional Exchange Program sponsored by the Caring Commission of the United Jewish Appeal-Federation of New York and JDC-ESHEL, The Association for the Planning and Development of Services for the Aged in Israel.1 The purpose of the Exchange was to share experiences of work with Holocaust survivors. Six delegates from New York City made site visits to survivor programs in Israel during the week of October 18–22. Delegates and program directors made presentations as well. Names and affiliations of the hosts and delegates appear in Appendix 1.
Mental Health Needs of Holocaust Survivors: Controversy and Consensus
Estimating the mental health needs of Holocaust survivors is not straight forward. Tauber2 indicated that the very terminology used to describe what happened to the Jews between 1939 and 1945 is freighted with multiple meanings whether the term is derived from Greek (“holokauston” or “burnt offering”), Hebrew (“shoah” or “catastrophe”), or German (“endloesung” or “final solution”). Multiple meanings also imply multiple traumas beyond events of the war including the stress of immigration, social isolation or marginalization, assimilation, and poverty, as well as episodes of mental illness that may have no direct link to the Holocaust.3 Kellerman4 suggested that persistent anti-Semitism along with the ongoing threat of war help perpetuate the stress of Holocaust survivorship in Israel.
The term “survivor syndrome,”5 which predates posttraumatic stress disorder (PTSD), described a constellation of symptoms, including an anxiety syndrome accompanied by chronic insomnia and nightmares as well as chronic depression characterized by isolation and seclusion.6 However, these findings emerged from clinical and case studies rather than representative samples assessed with replicable measurement techniques. As such, they overestimate vulnerability and underestimate the resilience of the larger population of survivors.7 Survivor syndrome has also fallen out of favor for implying that surviving the Holocaust is itself a mental illness. Thus, the identification of mental distress and mental disorders is a particularly sensitive matter to survivors, their family members (“the second generation”), and mental health professionals.
Lacking an explicit definition of Holocaust survivorship, Kennedy and colleagues8 found elevated levels of depressive symptoms among older Bronx, New York residents who identified themselves as Jewish. Although poor health and disability were the major determinants of the prevalence, emergence, and persistence of depressive symptoms, Jewish religious preference remained significantly associated with depression even when age, gender, social support, and medical conditions were taken into account. Among the Jewish sample, immigration from Eastern Europe (Russia, Poland) was a major predictor of depressive symptoms. Sharon and colleagues9 compared European-born Jews who had fled Nazi-occupied territory before 1939 or who immigrated to Israel from after World War II until 1950 with European-born Jewish Israelis and people born in Israel whose fathers had been born in Europe. They found no differences in the prevalence of depressive disorders or PTSD or use of mental health services between the two groups, but demonstrated substantial elevations in anxiety disorders, sleep disturbances, and general emotional distress among the Holocaust survivors.
A survey10 of people admitted to an Israeli psychiatric hospital and a subsequent meta-analysis11 of the literature found significantly increased risk of suicidality among Holocaust survivors. Wertman and colleagues12 found rates of clinically diagnosed dementia among older community residents of Jerusalem to be three times the estimated age-related prevalence found in other nations. Summarizing their own work and the literature at large, Kahana and colleagues7 found there is a “consistent picture of a small but statistically significant elevation in indicators of psychological distress” among survivors. They warned against diagnostic categorization, preferring to see Holocaust survivors as a group who are “physically and socially well functioning but wounded story tellers” who must bear witness.
Flamm-Oren and Plosker13 found that 44% of survivors had been prescribed an antidepressant and 44% complained of disturbed sleep with multiple awakenings. However, citing unpublished data from Brodsky and King, they reported that only 2% had availed themselves of mental health services, suggesting that most of the antidepressant prescriptions were written by primary care physicians (PCPs) rather than psychiatrists. Delegate Byrne,14 in her presentation on the Jewish Community Center of the Greater Five Towns, indicated that mental health services were integrated into the social support programs but were “camouflaged” to make them more acceptable to survivors.
Beyond the reluctance of survivors to seek mental health care is the lack of healthcare personnel trained to meet the needs of older adults in general and Holocaust survivors in particular. The World Health Organization finds available mental health services in both the more and less developed nations to be characterized by scarcity, inequity, and inefficiency.15 In the United States, there are only 7,100 geriatricians for >34 million seniors and the number of geriatricians is declining. There are ~1,600 geriatric psychiatrists with half the training programs positions unfilled. There are <1% of nurses and pharmacists and <4% of social workers specialized in geriatrics.16
Although this brief survey does not do justice to the sizeable literature on the mental health of survivors, it is sufficient to confirm that their needs are no less and may be considerably more than the average aged community resident. It also displays the ambivalence with which mental health needs of survivors are viewed by authorities within the mental health community. Some focus more on the Holocaust, avoiding stigmatization, and others more on the treatment. With rare exception,17 dementia is not a salient concern.
Declining Numbers, Increasing Needs, and Increasing Costs of Care
For his presentation, delegate Kover18 of the Selfhelp Community Services Nazi Victim Services assembled data from numerous sources to characterize demographic trends among survivors in the New York metropolitan area. Of the worldwide population of 786,900 survivors, 16% or 109,000 live in the US and 50% of that number resides in and around New York City. Their median age in 2008 was estimated to be 78 years. However, of people receiving Nazi Victim Services, 73% were ≥80 years of age. Greater than 25% of the group reported their health to be poor, an attribute closely linked to both the prevalence and incidence of depression among older Jewish community residents.8 In 2008, Selfhelp served 5,629 Nazi victims, representing 22.87% of the victims ≥75 years of age in the New York metropolitan area. With no reduction in the number of people applying for services and at an annual cost per client of $1,206 and 4% cost of living increases, the total costs of service are projected to increase from $6,790,243 in 2008 to $8,998,654 by 2015. Among this age group, dementia would be expected to affect no less than 14% of the population, tripling their healthcare costs.19 In summary, over the next 5–10 years, the number of Holocaust survivors remaining will decline, but because of advancing age and frailty their needs for supportive services and medical care will increase. Failure to address these needs will inevitably burden their family members and communities.
Mental Health Services Models for Holocaust Survivors
Founded in 1987 by Israeli Holocaust survivors to develop preventative and therapeutic services while minimizing the stigma of mental health care, AMCHA provides services to 9,000 Israeli survivors through support from the Conference on Jewish Material Claims against Germany, better known as the “Claims Conference.” Kellerman described AMCHA’s Social Clubhouse program as a vehicle to introduce therapeutic, psychosocial and recreational projects for survivors, augmented by programs developed to reach out to the homebound. During the delegation’s visit to one such clubhouse in Rehovot, it was clear that those in attendance took responsibility for reaching out to one another as well as recruiting other survivors for participation. They also served a monitoring function when one of their members became in need of services at home. AMCHA also provides training and support programs for caregivers and seems ideally prepared for dementia care services.
During his presentation to the delegates, Kellermann20 emphasized that Holocaust survivorship “is not a mental illness” but that AMCHA’s long history of mental health care now encompasses biomedical as well as psychosocial approaches including medications for depression and PTSD. His presentation and publication4,20 also detail how anti-Israel sentiments and threat of war are ongoing stressors for survivors living in Israel. AMCHA has achieved an enviable model of supportive services to generate a community which enhances the individual’s sense of self-reliance but also sets the stage for that minority of people in need of formal counseling. AMCHA has also performed pioneering work examining the reactions of therapists in their work with survivors.2
In contrast, the Bronx Holocaust Survivors Project is a collaborative care model between a community-based agency and an academic medical center. The agency, Selfhelp Community Services—“The Source for Independent Living”—through its Nazi Victim Community Services component, has an established mission of socially supportive services to Holocaust survivors in the New York metropolitan area. Agency support includes but is not limited to funds from the Claims Conference. The mission of Montefiore Medical Center’s Division of Geriatric Psychiatry includes teaching and training of health professionals in mental health care of older adults as well as psychiatric services in the clinic, nursing homes, and the patient’s home. Delegate Kennedy’s presentation21 described how >150 individuals were seen by geriatric psychiatrists over a 10-year period accounting for >700 visits, ~50% in the patient’s home. Patients were referred by Selfhelp caseworkers and other social service agencies who had established a collaborative relationship with the Medical Center made possible by the support of the J.E. and Z.B. Butler Foundation.
Half of the referrals were made for dementia management and capacity assessment requiring a home visit. These cases tended to be complex, time consuming, and without easy solutions. Most often the goal became sustaining the balance between patient preferences and safety. Family guilt, anger, and denial of the threat to the patient’s safety were recurring themes. Although applications for a court-ordered guardianship did occur, most often concerns were managed with “watchful waiting” and honoring patient’s preference. Much of the work for the psychiatrists was simply sharing the burden of case worker’s distress. The remaining referrals were for anxiety or depression and most often addressed with an office visit. Caseworkers also made referrals because their client had experienced a recent loss, the onset of disability, or had begun to talk about death. Psychotherapy was often focused on reminiscence and end of life issues, medications, and family matters. Cognitive impairment if present was not the main concern. The psychiatrist frequently lead the care coordination effort by contacting the PCP or securing the services of the Medical Center’s Division of Geriatric Medicine, which also had the capacity to make house calls either by physicians or a geriatric nurse practitioner.
Social Support Models That May Include A Mental Healthcare Component
Community-based programs focused on social interaction and informal support offer a bridge to mental health services for Holocaust survivors, provided the services are integrated into the fabric of the program in ways that reduce the stigma of mental illness and mental health care. Programs such as those described for AMCHA are fully integrated. Comparable mental health efforts of a lesser magnitude are apparent in the Jewish Community Center of the Greater Five Towns and The Samuel Field Y (both on Long Island) as well as the Edith and Carl Marks Jewish Community House of Benson Hurst of Brooklyn where mental health providers can be seen on site. The availability of Russian-speaking providers at Benson Hurst site is essential to that community.
In Israel, numerous novel community-based initiatives may prevent milder forms of mental illness through improvements in perceived social support and reduced isolation. They also offer the promise of early detection of more disabling mental disorders. These include the “Warm Home Program” for Holocaust survivors who immigrated from the Former Soviet Union. One community resident receives a small stipend to host the program in his or her home under the supervision of a social worker. The “Witness Theatre” pairs survivors with youthful students to produce a theatrical performance recounting the individual’s Holocaust experience. “Café Europe” events offer survivors food and music to elicit their participation in a support center without labeling the event as supportive. Supported housing through Amigour Senior Housing, largely for immigrants from the former Soviet Union, is similar to the Naturally Occurring Retirement Community programs in the US. However, supportive services are provided by a “community father or mother” who knows each resident and will perform minor repairs as well as engage family members or medical services if needed. The Reuth ESHEL Information Center is a hospital-based telephone information and referral service publicized by radio announcements and staffed largely by retired professionals but coordinated through a computerized information management and an outsourced telephone answering service. Evidence-based protocols for dementia caregivers and psychotherapy for depression delivered by telephone seem a readymade extension of this Center’s competence.
Each of these programs has successfully engaged survivors but require external support to do so. Some lack any identified mission of mental health care; none are economically viable mental health service delivery systems. Programs in both New York and Israel could benefit from greater collaboration between community-based agencies and academic medical centers. As one example, a care coordination model would position caseworkers and psychiatric social workers in the agencies to perform all the case finding and most of the counseling and psychotherapy. They would be backed up by geriatric psychiatrists capable of making in-home assessments when impaired decisional capacity, psychosis, or suicidality emerged. The psychiatrists would also provide team supervision and consultation with other physicians, including geriatricians. Much of the coordination and patient support would be accomplished by phone once a relationship of trust was established. Such a model is analogous to the integration of mental health providers into primary practices, which has been shown to improve the outcomes of both depression care22 and dementia management.23 In summary, an efficient, accessible chain of mental health care would be anchored in the least threatening setting, staffed principally with social workers and assisted by the participation of volunteers and telephone-facilitated coordination, and use psychiatrists with specialty training in geriatrics for staff support and for the minority of patients needing psychiatric assessment.
However, as presented in Appendix 2,2,4,24-29 counseling and psychotherapy with Holocaust survivors is not simple. Collaboration between community-based agencies and academic medical centers would need to be preceded by mutual needs assessment to initiate new services or enhance existing services for Holocaust survivors. Additional work would be required to mature and refine an alliance. Announcements on radio, in community centers, and to religious and social organizations would be needed to ensure awareness of the initiative and to ramp up demand while time remains. Moreover, if successful, these collaborations could efficiently extend the reach of scarce mental health services to the generation of older adults who will follow the last of the Holocaust survivors. The delegates’ enthusiasm evident at the end of the week suggests the effort can be engaged. PP
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