Primary and secondary care services are charged with failing to adequately detect and treat mental disorder in older adults due to the ‘understandability phenomenon’; the belief that mental disorder in old age is inevitable and therefore not worthy of intervention. Quantitative data appear to support this hypothesis but lack the explanatory power of detailed accounts. Nine general practitioners (GPs) participated in group interviews about their assessment and treatment of older patients, and their expectations and experience of referral to secondary care. Resulting transcripts were subject to Thematic Analysis. Respondents recognised the unique features of these clients, and their impact on the detailed, recursive processes of assessment, clinical decision-making and intervention. GPs described confidence in managing most cases of mental disorder, describing the role of secondary care as one of consultancy in extreme or unusual cases. GPs did view mental disorder as commonly originating in adverse circumstances, and queried the validity of pharmacological or psychological interventions in these cases. They did not, however, equate understandability with acceptability, and called for social interventions to be integrated with health-care interventions to tackle the cause of mental disorder in older adults. At a wider level, findings highlight the discrepancy between assumptions about GP attitudes and actions, and their own accounts. At a local level, findings will assist in focusing secondary care service development where need is perceived, into consultancy and training.

The diagnostic process after referral to an acute psychiatric treatment facility consists of more than the clinical investigation and laboratory tests. Psychometric tests in a broad range of languages may be such an augmentation of our diagnostic armamentarium, especially for immigrants for whom oral understanding of a dialogue may be restricted. The aim of this study was to discover whether such tests are in use, and how they are distributed among different patient categories. All referrals in one calendar year (N = 1168), as they are depicted in the hospital computerized medical records, were investigated. Fifty-six (6.1%) out of 926 ethnic Norwegians and six (3.0%) out of 198 non-Western immigrants were tested, whereas none of the 44 Western immigrants were. The difference between ethnic Norwegians and the immigrants was significant (Z = −3.05 and p = 0.002). Psychometric tests were thus almost not in use, and even less so in immigrants.

The mean number of resident days was higher among those tested, 11.7 (SD = 11.2), versus those not tested, 7.4 (SD = 10.4) days (t = 2.97 and p = 0.004). Among those tested, length of stay was not significantly different; 11.4 and 11.7 days respectively. The patients tested were older than those not tested. Mean age was 43.0 (SD = 14.4) versus 38.8 (SD = 12.1), with t = 2.65 and p = 0.03. Ethnic Norwegians had the longest mean stay, followed by Western immigrants and non-Western immigrants. The difference in resident days between all immigrants and ethnic Norwegians was significant with Z  =  −2.232 and p = 0.026. There was no such difference between Western and non-Western immigrants: Z = −0.057 and p = 0.95. The level of testing was higher in ethnic Norwegians, and the tested patients stayed longer, maybe indicating more time for testing. Whether this low test activity influences treatment quality is an unsettled question.