At the Intersection of Health, Health Care and Policy Cite this article as: Jonathan S. Bor Among The Elderly, Many Mental Illnesses Go Undiagnosed Health Affairs, 34, no.5 (2015):727-731 doi: 10.1377/hlthaff.2015.0314
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/34/5/727.full.html
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2015 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Entry Point
Depression care: In Northern California, Elizabeth, age sixty-six, was referred by her primary care provider to a depression care manager who, as part of the IMPACT model, helped manage her medications, coordinated with her doctors, and provided counseling. For the first time in more than twenty years battling depression, Elizabeth has begun to feel better. doi:
10.1377/hlthaff.2015.0314
Among The Elderly, Many Mental Illnesses Go Undiagnosed Few health care providers have the training to address depression, anxiety, and other conditions in their older patients. BY JONATHAN S. BOR
B
y now, warnings about the impact of an aging population on the nation’s health care system have become familiar: rising numbers of seniors with diabetes, heart disease, and other chronic illnesses; increased costs; and a strained geriatric workforce Photograph by Don Battershall
that is insufficient to meet even today’s needs. But despite well-publicized alarm over Alzheimer’s disease, whose victims are expected to triple by 2050,1 scant attention has been paid to non-dementiarelated mental illnesses such as depression and anxiety. Perhaps that’s because the problem is
hiding in plain sight. Many physicians aren’t trained to recognize mental illness in the elderly, patients are often reluctant to discuss their emotional difficulties, and some even blame themselves for not being happier, according to advocates for the mentally ill and physicians trained in geriatric psychiatry. Also, clinicians and, indeed, the patients themselves often miss mental disorders that may exist alongside and complicate physical illnesses that seem to stand out in bolder relief. But in a 2012 report the Institute of Medicine (IOM) estimated that 5.6– 8.0 million senior citizens had one or more mental or substance abuse conditions, with the number predicted to increase to 10.1–14.4 million by 2030.2 The IOM noted that the nation already didn’t have nearly enough professionals with the necessary training to diagnose and treat seniors with mental illness. Without a concerted effort to train more, the shortfall will grow sharply worse in years to come. The report called for the training of not only geriatric specialists but also direct care workers and peer support providers who can screen patients and provide brief interventions.
Long-Simmering Problems The IOM report wasn’t the first to warn of a growing shortfall. In 1999 a consensus conference convened by the University of California, San Diego, and led by Dilip V. Jeste, a geriatric psychiatrist there, predicted “an upcoming crisis” in geriatric mental health. The pool of trained personnel, the research infrastructure, and mental health delivery systems were inadequate to address the growing ranks of seniors with mental illness.3 Today, Jeste sees no reason to temper that forecast, noting as an example that fewer than half of the nation’s fellowship positions in geriatric psychiatry are currently filled—far fewer than in the late 1990s. Although the number of mentally ill older adults is increasing, “the number of experts is actually going down,” says Jeste, a past president of the American Psychiatric Association. “It’s embarrass-
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Entry Point ing and shameful for society.” He attributes the shrinking workforce to many factors including low reimbursement for mental health providers and what he considers a mistaken belief that the field is unexciting and the elderly difficult to treat. “A major problem is stigma,” Jeste adds. “People say, ‘Why do you want to work with older people? Mental illness is not curable. Old age is bad.’” Experts in geriatric behavioral health are quick to assert that mental illness is just as treatable in the elderly as in younger people but that it takes special skills to recognize the symptoms and understand the nuances of diagnosing and treating this population. As an example, Jeste notes that depression, by its strictest definition, is less prevalent among the elderly than among younger people.3 Typically, physicians diagnose major depression when a patient exhibits five of nine classic symptoms on a checklist, but many elderly people suffer from a condition that’s classified as “sub-syndromal” because they meet only three or four of the criteria. Older people, for instance, are less likely to feel sad or have crying spells than younger adults but more likely to complain of physical symptoms such as body aches, sleeplessness, and poor appetite, he explains. As Jeste observes, sub-syndromal depression can be just as debilitating as major depression, but the fact that it falls short on a score sheet might account for the widely held belief that depression is relatively uncommon in the elderly. Also, because depression can trigger pain, clinicians sometimes mistake it for a physical illness. Many also regard the symptoms, both physical and emotional, as inevitable features of aging, not features of an underlying mental disorder. “[Depression] is commonly misattributed to old age, so if an older person is not socializing, eating, or sleeping well, you may say, ‘Of course, what do you expect at this age?’ while the person may actually have early signs of depression,” says Jeste. Similarly, symptoms of anxiety may seem a normal part of aging. With advancing frailty, for instance, older adults may justifiably worry about falling. But, according to Jeste, the fear can become a 728
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paralyzing phobia, so intense that a person may hesitate to ever leave the house. Prescribing treatments for geriatric patients with mental illness is another challenge for health care providers. As patients age, the body’s ability to metabolize and excrete medications declines, so drugs can accumulate and cause more intense effects and side effects, Jeste says. A guiding principle for clinicians, he says, is to “start slow and go slow” with medications. Also, older adults might suffer from one or more chronic illnesses such as diabetes or hypertension, so doctors prescribing psychotropic medications need to consider possible interactions with drugs taken for those conditions. For older adults, depression or anxiety may be a problem of long standing or a new one brought on by the realities of outliving friends, living in isolation, or coping with physical infirmities. In its report, the IOM found that depression, whether recurring or late onset, was the most common mental illness seen in the elderly.2 “Someone who has heart failure and arthritis and has suffered various losses may start developing depression,” says Bruce Leff, a Johns Hopkins geriatrician. Because older adults with depression may not describe themselves as sad, the condition can be easy to miss. “If you asked them if they feel sad, they might say, ‘Not really,’” says Leff. “Yet many are suffering so-called vegetative symptoms that interfere with their ability to socialize, get a good night’s sleep, or eat properly.” Perhaps this helps explain why many seniors don’t seek help for the depression that’s keeping them from enjoying life. Paul Gionfriddo, president and CEO of Mental Health America, a patient advocacy organization, says that only about a third of elderly adults who took a depression screen on the organization’s website said they were going to do anything with the results, including seeing their doctor if they screened positive. It remains to be seen whether the Affordable Care Act’s provision of an annual wellness visit for Medicare patients will create an atmosphere of greater openness about mental health among both physicians and their older patients. The law requires that the visit include screening for depression as well as 34:5
cognitive impairment and functional abilities. “People often just don’t know how to start having this conversation,” Gionfriddo says. “They don’t know whether they want to bother their primary care doctor with it. That’s one side, but the other is that people think they can make themselves a little happier. They think they’ve managed their whole lives and gotten this far, they should be able to manage without getting into a big thing.” On the other hand, some patients who suffered mental illnesses early in life “age out” of the worst symptoms as they age. Patrick Hendry, vice president for consumer advocacy at Mental Health America, has been battling bipolar illness his entire adult life. At age eighteen he began having mild manic episodes (called hypomania), but by his thirties he started alternating between deep depressions and high manias. He was hospitalized fifteen times in seven years. At one point, he decided he was meant to be homeless and so he lived on the streets, refusing to accept money from his wife, whom he would eventually divorce. Hendry had once been a precious stone wholesaler and built two successful businesses, but he lost those as well. At sixty-five, Hendry finds that he’s able to manage his symptoms better than before. He recognizes their early signs and takes steps to alleviate them before they become crippling. For this reason, he considers himself among the lucky seniors for whom aging, in some respects, has brought relief. “We are more accustomed to living with illness, understanding it better. We know from experience what works and what doesn’t.” But Hendry’s brother, who is sixtyeight, has been less fortunate. He, too, struggled with bipolar illness for much of his life, although his symptoms for many years were less severe than Patrick’s. (Hendry asked that his brother’s name not be used.) A corporate executive, Hendry’s brother managed his symptoms until, about eight years ago, he was laid off and found himself unable to get hired. In recent years he’s taken menial jobs at Walmart and grocery stores, earning barely above minimum wage. Now he lives on Social Security,
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shares a small apartment with someone he didn’t previously know, and has lost touch with most of his friends. “This has brought on a whole new set of stressors and created other symptoms,” says Hendry. “For instance, [my brother] never had anxiety before, and while he had depression before, it’s gotten worse.”
New Models Of Care
Some older adults fear that by visiting a specialized clinic they will be labeled a psychiatric patient, a designation that for some is still loaded with shame.
At Mental Health America, Hendry runs a pilot program that offers what he calls “social self-directed care” to people with severe mental illness such as bipolar disorder and schizophrenia. Some also suffer from depression, anxiety, or both. Aimed at impoverished patients living on Supplemental Security Income, the program teaches people the skills they need to venture back into the community and meet new people. Most of the clients receive outpatient care at publicly funded community mental health centers. Although the pilot is small and hasn’t yet published empirical data, Hendry says he’s seen increases in overall health outcomes, quality of life, and feelings of self-esteem. For the older adults with mental illness, much of the innovation in care delivery has centered on models of care that integrate behavioral and physical health in the same setting. Such practices generally include primary care doctors who are trained to talk to patients about their mental health, psychiatrists who recommend treatment plans and consult on difficult cases, and case managers who help patients remain focused on care and monitor progress. In 2004 Stephen J. Bartels, professor of psychiatry and community and family health at the Dartmouth Institute, reported results of a large multicenter trial that compared an enhanced referral model to integrated care.4 In this model, patients who screened positive for a mental health or drinking problem were referred by their primary care doctors to specialty psychiatric services offered at a separate site. In the integrated model, primary care and psychiatric and substance abuse services were located in the same clinics. There, a patient with mental difficulties might get help from a psychiatrist or from a psychologist, psychiatric nurse, or other nonphysician provider. Primary care doctors and
mental health providers worked together to coordinate care and decide on treatment plans. The trial results showed that patients in the integrated settings were much more engaged in care than those who received referrals. For instance, while only 30.0 percent of patients in the referral model returned for subsequent mental health visits, 53.6 percent of patients in the integrated care models did. The integrated model was also associated with a larger number of total visits for depression, alcohol use, and dual diagnosis, but not for anxiety. The researchers also found that physical proximity between the primary care doctor and mental health specialist made a big difference in a patient’s utilization: the greater the distance, the less likely the patient was to go for help. Experts believe there’s another reason why, for many geriatric patients, psychiatric care works better in a primary care setting than in a specialized clinic. Some older adults, for example, fear that by visiting a specialized clinic they will be labeled a psychiatric patient, a designation that for some is still loaded with shame. “For many people in that generation, being treated for a mental health problem is still stigmatized,” says Jürgen Unützer, chair of psychiatry at the University of Washington, where he directs the Division of Integrated Care and Public Health. “People are not comfortable saying, ‘I’m depressed.’ It remains a challenge though I think it’s getting better.” With funding from the John A. Hartford Foundation, Unützer in the early 2000s field-tested a model of integrated care that was based on his observations that older patients with depression were not receiving the right kind of help in primary care. He estimates
that half of the patients weren’t being diagnosed at all, and many who were diagnosed weren’t receiving the right prescriptions. Recognizing that older patients generally don’t go to psychiatrists and that there will never be enough geriatric psychiatrists anyway, Unützer decided to “go where the patients go”— to primary care. In his IMPACT (Improving MoodPromoting Access to Collaborative Treatment) model of care, a patient’s primary care provider works with a care manager—a nurse, psychologist, or social worker—to develop a treatment plan. A staff psychiatrist consults on new cases and on difficult ones in which patients haven’t improved with treatment. When patients don’t respond to a second line of therapy, the treatment team reviews the case again and considers steps such as medication changes, psychotherapy, or hospitalization. In a 2002 article published in the Journal of the American Medical Association, Unützer reported that 45 percent of patients assigned to integrated care had a 50 percent or greater reduction of depressive symptoms, compared to 19 percent of patients assigned to usual care. He defined usual care as the use of any primary care or specialty care services available to patients.5 Since that trial, Unützer’s group has worked with nearly 1,000 practices across the country to integrate physical and mental health along these lines; the largest concentrations are in Washington, Minnesota, California, and New York. “It might seem like a lot to say that we’re doing this in a couple hundred practices, but probably a couple hundred thousand is what’s needed,” says Unützer. In Washington State, funding comes partly from Medicare and partly from a local tax levy on residents. Other practices and systems are adopting the principles of care integration for seniors with mental illness. For example, Milwaukee-based Aurora Health Care, which comprises fourteen acute care hospitals and 120 practices across Wisconsin, has adopted a paradigm for examining the interplay of mental and physical factors in its geriatric patients’ health. In reviewing cases, treatment teams consisting of physicians and nurses and, in some cases, physical therapists start by drawing a
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Entry Point star on a white board. Above the star’s top point, someone writes the patient’s medical problem; soon, the other points carry information about the patient’s medications, social needs, behavioral health needs, and personal needs including the meaning of the illness to the patient or caregiver. “In the middle of the star, we simply articulate and list the hardest aspect or the most challenging aspect of the circumstances for the patient,” says Michael Malone, medical director of senior services at Aurora. He says that the star system has “changed the trajectory of our practice” by giving treatment teams a way to understand the intersection of a patient’s physical and emotional needs as well as the potential interactions—good and bad—of medications. “It’s well known that if an older person has an acute medical problem, say ischemic heart disease, plus depression, their morbidity and mortality is higher than if they have ischemic heart disease alone,” says Malone. “Our hospitalists, primary care physicians, and our specialists need to recognize the possibility of concurrent behavioral health needs of a vulnerable elder so they can properly manage the case.” Health care systems will also have to grapple with rising numbers of ethnic minorities in the elderly population— particularly Hispanics and Asians—who will require a more diverse workforce to help bridge language and cultural differences.2 Census projections indicate that the proportion of older adults who are non-Hispanic whites will decline to 72 percent by 2030, a 9-percentagepoint drop since 2003. “Some [older immigrants] have come to this country late in life and have pretty much remained in ethnic or linguistic enclaves,” says Margarita Allegria, director of the Center for Multicultural Mental Health Research at the Cambridge Health Alliance, in Massachusetts. Some may feel a deep sadness about friends, family, and familiar places left behind, Allegria says. Even when offered services, they may have trouble understanding the terminology of treatment, including key phrases such as “negative thoughts,” she adds. With funding from the National Institute on Aging, the Cambridge center 730
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There are hopeful signs that mental illness in the elderly may finally be receiving the attention it deserves. trains local residents who are fluent in English and either Spanish, Mandarin, or Cantonese in principles of cognitive behavioral therapy, a short-term approach to depression aimed at solving problems and curbing unhelpful behaviors. The trainees are beginning to provide first-line, one-on-one counseling to patients at community agencies. Although Allegria is hopeful about the program’s potential to help older immigrants, she cautions that the model requires considerable resources, such as qualified staff who are freed up to train and supervise recruits.
Persistent Barriers Despite signs of innovation in geriatric mental health, there remain barriers to spreading even the most promising models widely. One of the barriers, says Unützer, is the stigma felt by many older adults toward mental illness—even their own. Also to be considered are enduring cultural differences between the disciplines of primary care and psychiatry. “It’s more than just saying ‘put a mental health provider in your practice’—it’s also working collaboratively in ways they’re not used to,” he says. Also, in fee-for-service Medicare, practices can charge for a patient visit but not for essential aspects of care management such as conversations between providers, telephone calls with patients, or a psychiatrist reviewing charts and recommending treatment. Writing two years ago in the New England Journal of Medicine, Bartels lamented that mental health services accounted for only 1 percent of Medicare spending despite evidence that older adults with mental illness have higher rates of hospitalization and emergency department visits than people with physical illnesses alone. This results in “per-person costs that are 47 percent to more than 200 percent higher.”6 He says that the nation could treat more seniors with mental 34:5
disorders by training more health coaches and community health workers to provide health screenings and brief interventions. Evidence that such solutions can work come from unconventional sources: trials in Goa, India, Chile, Pakistan, and Uganda, he says.6 Additionally, Bartels echoed the IOM’s concern2 that there is no single federal agency responsible for addressing the plight of older adults with mental illness, remarking that workforce development “falls into a crack between federal agencies responsible for mental health and substance abuse and those responsible for aging.” At the same time, he notes that a decade-old federal grants program that helped communities meet the mental health needs of its older residents has been eliminated and that older adults have long been underrepresented in federally funded research studies. On the other hand, there are hopeful signs that mental illness in the elderly may finally be receiving the attention it deserves. For instance, Unützer says the movement toward accountable care organizations could trigger more widespread adoption of integrated care models, especially in light of evidence that IMPACT clinics saved money on total downstream costs.7 The proliferation of patient-centered medical homes could help, too. Last year, the National Committee for Quality Assurance, a national nonprofit that certifies patient-centered medical homes, raised the requirements for practices to receive level 3 accreditation, the highest possible ranking. Under these new requirements, practices must demonstrate that they have the capacity to screen for and manage mental health problems. As some payers reimburse level 3 providers more generously than others, the incentive to find proven models of care continues to grow. “The kind of practices needing this are coming to us,” Unützer says. “When we did this research and published in the early 2000s, the phrase ‘Triple Aim’ hadn’t been invented yet,” he says. “But what we got was an early example. If you do this well, that’s exactly what you get: better patient satisfaction, better health outcomes, and better access along with some cost reductions.” ▪
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Jonathan S. Bor ([email protected]) is a senior editor and correspondent at Health Affairs, in Bethesda, Maryland.
NOTES 1 National Institute on Aging. 2012–2013 Alzheimer’s disease progress report: seeking the earliest interventions [Internet]. Bethesda (MD): NIA; [cited 2015 Mar 27]. Available from: http:// www.nia.nih.gov/alzheimers/ publication/2012-2013alzheimers-disease-progressreport 2 Institute of Medicine. The mental health and substance use workforce for older adults: in whose hands? [Internet] Washington
(DC): National Academies Press; 2012 Jul [cited 2015 Mar 27]. Available from: http://www.iom .edu/Reports/2012/The-MentalHealth-and-Substance-UseWorkforce-for-Older-Adults.aspx 3 Jeste DV, Alexopoulos GS, Bartels SJ, Cummings JL, Gallo JJ, Gottlieb GL, et al. Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades. Arch Gen Psychiatry. 1999; 56(9):848–53.
4 Bartels SJ, Coakley EH, Zubritsky C, Ware JH, Miles KM, Areán PA, et al. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry. 2004;161(8):1455–62. 5 Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, et al. Collaborative care management of late-life depres-
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sion in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45. 6 Bartels SJ, Naslund JA. The underside of the silver tsunami— older adults and mental health care. N Engl J Med. 2013;368(6): 493–6. 7 Unützer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95–100.
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The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/34/5/727.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2015 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on July 8, 2015 at Universite Laval
Entry Point
Depression care: In Northern California, Elizabeth, age sixty-six, was referred by her primary care provider to a depression care manager who, as part of the IMPACT model, helped manage her medications, coordinated with her doctors, and provided counseling. For the first time in more than twenty years battling depression, Elizabeth has begun to feel better. doi:
10.1377/hlthaff.2015.0314
Among The Elderly, Many Mental Illnesses Go Undiagnosed Few health care providers have the training to address depression, anxiety, and other conditions in their older patients. BY JONATHAN S. BOR
B
y now, warnings about the impact of an aging population on the nation’s health care system have become familiar: rising numbers of seniors with diabetes, heart disease, and other chronic illnesses; increased costs; and a strained geriatric workforce Photograph by Don Battershall
that is insufficient to meet even today’s needs. But despite well-publicized alarm over Alzheimer’s disease, whose victims are expected to triple by 2050,1 scant attention has been paid to non-dementiarelated mental illnesses such as depression and anxiety. Perhaps that’s because the problem is
hiding in plain sight. Many physicians aren’t trained to recognize mental illness in the elderly, patients are often reluctant to discuss their emotional difficulties, and some even blame themselves for not being happier, according to advocates for the mentally ill and physicians trained in geriatric psychiatry. Also, clinicians and, indeed, the patients themselves often miss mental disorders that may exist alongside and complicate physical illnesses that seem to stand out in bolder relief. But in a 2012 report the Institute of Medicine (IOM) estimated that 5.6– 8.0 million senior citizens had one or more mental or substance abuse conditions, with the number predicted to increase to 10.1–14.4 million by 2030.2 The IOM noted that the nation already didn’t have nearly enough professionals with the necessary training to diagnose and treat seniors with mental illness. Without a concerted effort to train more, the shortfall will grow sharply worse in years to come. The report called for the training of not only geriatric specialists but also direct care workers and peer support providers who can screen patients and provide brief interventions.
Long-Simmering Problems The IOM report wasn’t the first to warn of a growing shortfall. In 1999 a consensus conference convened by the University of California, San Diego, and led by Dilip V. Jeste, a geriatric psychiatrist there, predicted “an upcoming crisis” in geriatric mental health. The pool of trained personnel, the research infrastructure, and mental health delivery systems were inadequate to address the growing ranks of seniors with mental illness.3 Today, Jeste sees no reason to temper that forecast, noting as an example that fewer than half of the nation’s fellowship positions in geriatric psychiatry are currently filled—far fewer than in the late 1990s. Although the number of mentally ill older adults is increasing, “the number of experts is actually going down,” says Jeste, a past president of the American Psychiatric Association. “It’s embarrass-
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Entry Point ing and shameful for society.” He attributes the shrinking workforce to many factors including low reimbursement for mental health providers and what he considers a mistaken belief that the field is unexciting and the elderly difficult to treat. “A major problem is stigma,” Jeste adds. “People say, ‘Why do you want to work with older people? Mental illness is not curable. Old age is bad.’” Experts in geriatric behavioral health are quick to assert that mental illness is just as treatable in the elderly as in younger people but that it takes special skills to recognize the symptoms and understand the nuances of diagnosing and treating this population. As an example, Jeste notes that depression, by its strictest definition, is less prevalent among the elderly than among younger people.3 Typically, physicians diagnose major depression when a patient exhibits five of nine classic symptoms on a checklist, but many elderly people suffer from a condition that’s classified as “sub-syndromal” because they meet only three or four of the criteria. Older people, for instance, are less likely to feel sad or have crying spells than younger adults but more likely to complain of physical symptoms such as body aches, sleeplessness, and poor appetite, he explains. As Jeste observes, sub-syndromal depression can be just as debilitating as major depression, but the fact that it falls short on a score sheet might account for the widely held belief that depression is relatively uncommon in the elderly. Also, because depression can trigger pain, clinicians sometimes mistake it for a physical illness. Many also regard the symptoms, both physical and emotional, as inevitable features of aging, not features of an underlying mental disorder. “[Depression] is commonly misattributed to old age, so if an older person is not socializing, eating, or sleeping well, you may say, ‘Of course, what do you expect at this age?’ while the person may actually have early signs of depression,” says Jeste. Similarly, symptoms of anxiety may seem a normal part of aging. With advancing frailty, for instance, older adults may justifiably worry about falling. But, according to Jeste, the fear can become a 728
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paralyzing phobia, so intense that a person may hesitate to ever leave the house. Prescribing treatments for geriatric patients with mental illness is another challenge for health care providers. As patients age, the body’s ability to metabolize and excrete medications declines, so drugs can accumulate and cause more intense effects and side effects, Jeste says. A guiding principle for clinicians, he says, is to “start slow and go slow” with medications. Also, older adults might suffer from one or more chronic illnesses such as diabetes or hypertension, so doctors prescribing psychotropic medications need to consider possible interactions with drugs taken for those conditions. For older adults, depression or anxiety may be a problem of long standing or a new one brought on by the realities of outliving friends, living in isolation, or coping with physical infirmities. In its report, the IOM found that depression, whether recurring or late onset, was the most common mental illness seen in the elderly.2 “Someone who has heart failure and arthritis and has suffered various losses may start developing depression,” says Bruce Leff, a Johns Hopkins geriatrician. Because older adults with depression may not describe themselves as sad, the condition can be easy to miss. “If you asked them if they feel sad, they might say, ‘Not really,’” says Leff. “Yet many are suffering so-called vegetative symptoms that interfere with their ability to socialize, get a good night’s sleep, or eat properly.” Perhaps this helps explain why many seniors don’t seek help for the depression that’s keeping them from enjoying life. Paul Gionfriddo, president and CEO of Mental Health America, a patient advocacy organization, says that only about a third of elderly adults who took a depression screen on the organization’s website said they were going to do anything with the results, including seeing their doctor if they screened positive. It remains to be seen whether the Affordable Care Act’s provision of an annual wellness visit for Medicare patients will create an atmosphere of greater openness about mental health among both physicians and their older patients. The law requires that the visit include screening for depression as well as 34:5
cognitive impairment and functional abilities. “People often just don’t know how to start having this conversation,” Gionfriddo says. “They don’t know whether they want to bother their primary care doctor with it. That’s one side, but the other is that people think they can make themselves a little happier. They think they’ve managed their whole lives and gotten this far, they should be able to manage without getting into a big thing.” On the other hand, some patients who suffered mental illnesses early in life “age out” of the worst symptoms as they age. Patrick Hendry, vice president for consumer advocacy at Mental Health America, has been battling bipolar illness his entire adult life. At age eighteen he began having mild manic episodes (called hypomania), but by his thirties he started alternating between deep depressions and high manias. He was hospitalized fifteen times in seven years. At one point, he decided he was meant to be homeless and so he lived on the streets, refusing to accept money from his wife, whom he would eventually divorce. Hendry had once been a precious stone wholesaler and built two successful businesses, but he lost those as well. At sixty-five, Hendry finds that he’s able to manage his symptoms better than before. He recognizes their early signs and takes steps to alleviate them before they become crippling. For this reason, he considers himself among the lucky seniors for whom aging, in some respects, has brought relief. “We are more accustomed to living with illness, understanding it better. We know from experience what works and what doesn’t.” But Hendry’s brother, who is sixtyeight, has been less fortunate. He, too, struggled with bipolar illness for much of his life, although his symptoms for many years were less severe than Patrick’s. (Hendry asked that his brother’s name not be used.) A corporate executive, Hendry’s brother managed his symptoms until, about eight years ago, he was laid off and found himself unable to get hired. In recent years he’s taken menial jobs at Walmart and grocery stores, earning barely above minimum wage. Now he lives on Social Security,
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shares a small apartment with someone he didn’t previously know, and has lost touch with most of his friends. “This has brought on a whole new set of stressors and created other symptoms,” says Hendry. “For instance, [my brother] never had anxiety before, and while he had depression before, it’s gotten worse.”
New Models Of Care
Some older adults fear that by visiting a specialized clinic they will be labeled a psychiatric patient, a designation that for some is still loaded with shame.
At Mental Health America, Hendry runs a pilot program that offers what he calls “social self-directed care” to people with severe mental illness such as bipolar disorder and schizophrenia. Some also suffer from depression, anxiety, or both. Aimed at impoverished patients living on Supplemental Security Income, the program teaches people the skills they need to venture back into the community and meet new people. Most of the clients receive outpatient care at publicly funded community mental health centers. Although the pilot is small and hasn’t yet published empirical data, Hendry says he’s seen increases in overall health outcomes, quality of life, and feelings of self-esteem. For the older adults with mental illness, much of the innovation in care delivery has centered on models of care that integrate behavioral and physical health in the same setting. Such practices generally include primary care doctors who are trained to talk to patients about their mental health, psychiatrists who recommend treatment plans and consult on difficult cases, and case managers who help patients remain focused on care and monitor progress. In 2004 Stephen J. Bartels, professor of psychiatry and community and family health at the Dartmouth Institute, reported results of a large multicenter trial that compared an enhanced referral model to integrated care.4 In this model, patients who screened positive for a mental health or drinking problem were referred by their primary care doctors to specialty psychiatric services offered at a separate site. In the integrated model, primary care and psychiatric and substance abuse services were located in the same clinics. There, a patient with mental difficulties might get help from a psychiatrist or from a psychologist, psychiatric nurse, or other nonphysician provider. Primary care doctors and
mental health providers worked together to coordinate care and decide on treatment plans. The trial results showed that patients in the integrated settings were much more engaged in care than those who received referrals. For instance, while only 30.0 percent of patients in the referral model returned for subsequent mental health visits, 53.6 percent of patients in the integrated care models did. The integrated model was also associated with a larger number of total visits for depression, alcohol use, and dual diagnosis, but not for anxiety. The researchers also found that physical proximity between the primary care doctor and mental health specialist made a big difference in a patient’s utilization: the greater the distance, the less likely the patient was to go for help. Experts believe there’s another reason why, for many geriatric patients, psychiatric care works better in a primary care setting than in a specialized clinic. Some older adults, for example, fear that by visiting a specialized clinic they will be labeled a psychiatric patient, a designation that for some is still loaded with shame. “For many people in that generation, being treated for a mental health problem is still stigmatized,” says Jürgen Unützer, chair of psychiatry at the University of Washington, where he directs the Division of Integrated Care and Public Health. “People are not comfortable saying, ‘I’m depressed.’ It remains a challenge though I think it’s getting better.” With funding from the John A. Hartford Foundation, Unützer in the early 2000s field-tested a model of integrated care that was based on his observations that older patients with depression were not receiving the right kind of help in primary care. He estimates
that half of the patients weren’t being diagnosed at all, and many who were diagnosed weren’t receiving the right prescriptions. Recognizing that older patients generally don’t go to psychiatrists and that there will never be enough geriatric psychiatrists anyway, Unützer decided to “go where the patients go”— to primary care. In his IMPACT (Improving MoodPromoting Access to Collaborative Treatment) model of care, a patient’s primary care provider works with a care manager—a nurse, psychologist, or social worker—to develop a treatment plan. A staff psychiatrist consults on new cases and on difficult ones in which patients haven’t improved with treatment. When patients don’t respond to a second line of therapy, the treatment team reviews the case again and considers steps such as medication changes, psychotherapy, or hospitalization. In a 2002 article published in the Journal of the American Medical Association, Unützer reported that 45 percent of patients assigned to integrated care had a 50 percent or greater reduction of depressive symptoms, compared to 19 percent of patients assigned to usual care. He defined usual care as the use of any primary care or specialty care services available to patients.5 Since that trial, Unützer’s group has worked with nearly 1,000 practices across the country to integrate physical and mental health along these lines; the largest concentrations are in Washington, Minnesota, California, and New York. “It might seem like a lot to say that we’re doing this in a couple hundred practices, but probably a couple hundred thousand is what’s needed,” says Unützer. In Washington State, funding comes partly from Medicare and partly from a local tax levy on residents. Other practices and systems are adopting the principles of care integration for seniors with mental illness. For example, Milwaukee-based Aurora Health Care, which comprises fourteen acute care hospitals and 120 practices across Wisconsin, has adopted a paradigm for examining the interplay of mental and physical factors in its geriatric patients’ health. In reviewing cases, treatment teams consisting of physicians and nurses and, in some cases, physical therapists start by drawing a
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Entry Point star on a white board. Above the star’s top point, someone writes the patient’s medical problem; soon, the other points carry information about the patient’s medications, social needs, behavioral health needs, and personal needs including the meaning of the illness to the patient or caregiver. “In the middle of the star, we simply articulate and list the hardest aspect or the most challenging aspect of the circumstances for the patient,” says Michael Malone, medical director of senior services at Aurora. He says that the star system has “changed the trajectory of our practice” by giving treatment teams a way to understand the intersection of a patient’s physical and emotional needs as well as the potential interactions—good and bad—of medications. “It’s well known that if an older person has an acute medical problem, say ischemic heart disease, plus depression, their morbidity and mortality is higher than if they have ischemic heart disease alone,” says Malone. “Our hospitalists, primary care physicians, and our specialists need to recognize the possibility of concurrent behavioral health needs of a vulnerable elder so they can properly manage the case.” Health care systems will also have to grapple with rising numbers of ethnic minorities in the elderly population— particularly Hispanics and Asians—who will require a more diverse workforce to help bridge language and cultural differences.2 Census projections indicate that the proportion of older adults who are non-Hispanic whites will decline to 72 percent by 2030, a 9-percentagepoint drop since 2003. “Some [older immigrants] have come to this country late in life and have pretty much remained in ethnic or linguistic enclaves,” says Margarita Allegria, director of the Center for Multicultural Mental Health Research at the Cambridge Health Alliance, in Massachusetts. Some may feel a deep sadness about friends, family, and familiar places left behind, Allegria says. Even when offered services, they may have trouble understanding the terminology of treatment, including key phrases such as “negative thoughts,” she adds. With funding from the National Institute on Aging, the Cambridge center 730
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There are hopeful signs that mental illness in the elderly may finally be receiving the attention it deserves. trains local residents who are fluent in English and either Spanish, Mandarin, or Cantonese in principles of cognitive behavioral therapy, a short-term approach to depression aimed at solving problems and curbing unhelpful behaviors. The trainees are beginning to provide first-line, one-on-one counseling to patients at community agencies. Although Allegria is hopeful about the program’s potential to help older immigrants, she cautions that the model requires considerable resources, such as qualified staff who are freed up to train and supervise recruits.
Persistent Barriers Despite signs of innovation in geriatric mental health, there remain barriers to spreading even the most promising models widely. One of the barriers, says Unützer, is the stigma felt by many older adults toward mental illness—even their own. Also to be considered are enduring cultural differences between the disciplines of primary care and psychiatry. “It’s more than just saying ‘put a mental health provider in your practice’—it’s also working collaboratively in ways they’re not used to,” he says. Also, in fee-for-service Medicare, practices can charge for a patient visit but not for essential aspects of care management such as conversations between providers, telephone calls with patients, or a psychiatrist reviewing charts and recommending treatment. Writing two years ago in the New England Journal of Medicine, Bartels lamented that mental health services accounted for only 1 percent of Medicare spending despite evidence that older adults with mental illness have higher rates of hospitalization and emergency department visits than people with physical illnesses alone. This results in “per-person costs that are 47 percent to more than 200 percent higher.”6 He says that the nation could treat more seniors with mental 34:5
disorders by training more health coaches and community health workers to provide health screenings and brief interventions. Evidence that such solutions can work come from unconventional sources: trials in Goa, India, Chile, Pakistan, and Uganda, he says.6 Additionally, Bartels echoed the IOM’s concern2 that there is no single federal agency responsible for addressing the plight of older adults with mental illness, remarking that workforce development “falls into a crack between federal agencies responsible for mental health and substance abuse and those responsible for aging.” At the same time, he notes that a decade-old federal grants program that helped communities meet the mental health needs of its older residents has been eliminated and that older adults have long been underrepresented in federally funded research studies. On the other hand, there are hopeful signs that mental illness in the elderly may finally be receiving the attention it deserves. For instance, Unützer says the movement toward accountable care organizations could trigger more widespread adoption of integrated care models, especially in light of evidence that IMPACT clinics saved money on total downstream costs.7 The proliferation of patient-centered medical homes could help, too. Last year, the National Committee for Quality Assurance, a national nonprofit that certifies patient-centered medical homes, raised the requirements for practices to receive level 3 accreditation, the highest possible ranking. Under these new requirements, practices must demonstrate that they have the capacity to screen for and manage mental health problems. As some payers reimburse level 3 providers more generously than others, the incentive to find proven models of care continues to grow. “The kind of practices needing this are coming to us,” Unützer says. “When we did this research and published in the early 2000s, the phrase ‘Triple Aim’ hadn’t been invented yet,” he says. “But what we got was an early example. If you do this well, that’s exactly what you get: better patient satisfaction, better health outcomes, and better access along with some cost reductions.” ▪
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Jonathan S. Bor ([email protected]) is a senior editor and correspondent at Health Affairs, in Bethesda, Maryland.
NOTES 1 National Institute on Aging. 2012–2013 Alzheimer’s disease progress report: seeking the earliest interventions [Internet]. Bethesda (MD): NIA; [cited 2015 Mar 27]. Available from: http:// www.nia.nih.gov/alzheimers/ publication/2012-2013alzheimers-disease-progressreport 2 Institute of Medicine. The mental health and substance use workforce for older adults: in whose hands? [Internet] Washington
(DC): National Academies Press; 2012 Jul [cited 2015 Mar 27]. Available from: http://www.iom .edu/Reports/2012/The-MentalHealth-and-Substance-UseWorkforce-for-Older-Adults.aspx 3 Jeste DV, Alexopoulos GS, Bartels SJ, Cummings JL, Gallo JJ, Gottlieb GL, et al. Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades. Arch Gen Psychiatry. 1999; 56(9):848–53.
4 Bartels SJ, Coakley EH, Zubritsky C, Ware JH, Miles KM, Areán PA, et al. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry. 2004;161(8):1455–62. 5 Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, et al. Collaborative care management of late-life depres-
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sion in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45. 6 Bartels SJ, Naslund JA. The underside of the silver tsunami— older adults and mental health care. N Engl J Med. 2013;368(6): 493–6. 7 Unützer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95–100.
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