Aging and Mental Health: The Troubles Facing the Current Geriatric Mental Health System

By Kacey Heekin (2015)

Mental illness in older adults isa prevalent condition that is associated with serious physical, social, and economic consequences. A significant percentage of older adults in the United States experience mental illness, although the exact prevalence of mental illness in older adults varies by definition and source. According to a report by Karel et al., 2012, approximately 20.4% of older adults experience a mental disorder. Common mental disorders in older adults include anxiety disorders, cognitive impairment, dementia, and mood disorders.

It is expected that as the number of older adults continues to increase, so too will the number of older adults experiencing mental health issues. The Institute of Medicine predicts that by 2030, the number of older adults with mental health and substance use conditions will increase by 80% (Institute of Medicine, 2012). Recently, greater attention has been devoted to the existing geriatric mental health system as a result of the continuing growth of the older adult population and the current shortcomings in the way this system treats mental health issues in older adults.

Issues Surrounding Aging and Mental Health

The U.S. mental health system in general has long existed in poor condition. This system has been continuously, critically underfunded and has been unable to provide adequate mental health services for far too many individuals in need, including older adults with mental health issues. Additionally, many of the problems within the general mental health system are especially prominent to older adults. For instance, the recognition/diagnosis of mental disorders in older adults can be particularly difficult because certain mental conditions can present as/cause symptoms of multiple disorders. Specifically, distinguishing between the diagnoses of depression, delirium, or dementia can be complicated. Furthermore, certain symptoms of mental illness can be mistaken as simply symptoms of aging. The presentations/symptoms of mental disorders in older adults can also differ somewhat from symptoms in younger populations.

Moreover, despite the high prevalence of geriatric mental disorders, geriatric mental health issues often go untreated. Research indicates that older adults with mental disorders are less likely than younger and middle-aged adults to receive mental health services, especially from mental health specialists (Karel et al., 2012). The barriers that older adults face to receiving proper mental health care can vary. Stigma associated with mental and emotional issues, especially in the current cohort of older adults, has been suggested as one such barrier. Other barriers include lack of information about available services, lack of transportation, and lack of money or insurance to pay for services. However, one of the greatest issues surrounding aging and mental health is the inadequate workforce of trained geriatric mental health providers. Current health care providers are not always familiar with the signs of mental illness in older adults, which is especially problematic among primary care physicians because many older adults only receive mental health care in primary care settings. Recruiting and/or preparing geriatric mental health providers is accompanied by additional obstacles, including: relatively few opportunities for specialization in geriatric mental health and little support or mentorship for those who do pursue specialization; lack of financial incentives to encourage geriatric mental health providers to enter and stay in this field; and inconsistent and little required professional training in geriatric mental health (Institute of Medicine, 2012).

Furthermore, the service delivery system for older adults is very fragmented. Primary care, mental health specialty services, community-based services, aging network services, home health care, nursing homes, assisted living facilities, and family caregivers are all settings or sources of possible geriatric mental health services. There is no comprehensive policy, however, to coordinate or integrate all of these different settings of potential services. State mental health departments often times do not coordinate with state departments that handle aging issues. This lack of coordination leaves geriatric mental health unaddressed.

The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?

For decades, policymakers have been warned that the nation’s health care workforce is ill-equipped—in numbers, knowledge, and skills—to care for a rapidly aging and increasingly diverse population. In the specific disciplines of mental health and substance use, there have been similar warnings about serious workforce shortages, insufficient workforce diversity, and lack of basic competence and core knowledge in key areas. These past calls to remedy inadequate training and to reverse serious shortages of personnel for MH/SU [mental health/substance use] care have gone unheeded.

–Institute of Medicine

Current Mental Health Services for Older Adults

A variety of services are required to meet the nation’s geriatric mental health needs. These services include prevention, screening, diagnosis, treatment, and monitoring. There are many evidence-based geriatric mental health services including mental health outreach, integrated care, case management, family/caregiver support, and pharmacological and/or psychosocial treatments.

Throughout the past 50 years, the setting for mental health services has largely transitioned from psychiatric hospitals to community-based facilities. Providing access to community-based mental health services better suited to older adults is critical. The integration of primary care and other mental health services is another especially important change for this demographic. System-based interventions for geriatric mental health care have received increased attention. There are several evidence-based models of care that are effective for managing geriatric mental health issues. Examples of evidence-based models of care for older adults regarding depression in particular include Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors), IMPACT (Improving Mood-Promoting Access to Collaborative Treatment), and PEARLS (Program to Encourage Active and Rewarding Lives for Seniors). PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) is an example of an effective, community-based model of care implementing case management for reducing suicide ideation in older adults with depression. The Institute of Medicine (2012) also identifies HOPES (Helping Older Persons Experience Success) and PREVENT (Providing Resources Early to Vulnerable Elders Needing Treatment) as effective programs for helping older adults with SMI residing in the community and older adults with Alzheimer’s disease and their caregivers, respectively. Despite the existence of these various models of care for geriatric mental health issues, implementation of these programs and access to care has remained limited.

Addressing Depression in Older Adults: Selected Evidence-Based Programs

IMPACT is a program for older adults who have major depression or dysthymic disorder. The intervention is a stepped, collaborative care approach in which a nurse, social worker, or psychologist works with the participants’ regular primary care provider to develop a course of treatment. Patients receiving IMPACT care were twice as likely as usual care patients to experience a 50% or greater reduction in depression symptoms. IMPACT patients also experienced greater rates of depression treatment, greater satisfaction with their depression care, less functional impairment, and better quality of life… IMPACT has been found to reduce total health care costs by about $3,300 per person over a four-year period compared to persons receiving usual care…”

–Centers for Disease Control and Prevention

The Future of the Geriatric Mental Health System – Recommendations for Improvement

Support for assessing and addressing the geriatric mental health system has recently gained momentum. Other positive changes include increased findings on the efficacy of interventions to sustain mental health throughout the aging process and subsequent outreach to disseminate such information, continuous improvement in the understanding of the etiology and presentation of geriatric mental illness, advancements in treatment options, implementation of evidence-based practices, parity for mental health services, expansion of mental health and substance use disorder coverage, and emphasis on the integration of health care.

However, the U.S. mental health system, and accordingly the geriatric mental health system, is still critically underfunded. Expansion of expenditures on mental health services in general, with particular consideration for geriatric mental health services, is critical. Recommendations for the movement toward a more effective geriatric mental health system include continued research on the diagnosis, etiology, and treatment of geriatric mental illnesses (especially dementia), support for the investigation of comparative cost-effectiveness of available geriatric mental health services, implementation of frameworks designed to improve the ability to measure quality of geriatric mental health care, development of and reliance on patient-centered outcomes, expansion of integrated care, application of evidence-based models of integrated care (e.g., IMPACT), and strengthening of the geriatric mental health workforce (e.g., through initiating financial incentives for geriatric mental health providers, standardizing training requirements, and emphasizing multicultural competency).