Overlooked and Underserved: Elders in Need of Mental Health Care
by: Trudy Persky, MSW, ACSW
Over the last decade there has been a striking number of articles in professional journals and the public press attesting to the high prevalence of psychiatric disorders in the nation's elderly population. Although adults 60 years of age and older constitute 13 percent of the United States population, their use of inpatient and outpatient mental health services falls far below expectations.
Elders account for only 7 percent of all inpatient psychiatric services, 6 percent of community mental health services, and 9 percent of private psychiatric care. Less than 3 percent of all Medicare reimbursement is for the psychiatric treatment of older patients. It is estimated that 18 to 25 percent of elders are in need of mental health care for depression, anxiety, psychosomatic disorders, adjustment to aging, and schizophrenia. Yet, few seem to receive proper care and treatment for these mental illnesses. It is also a distressing reality that the suicide rate of the elderly stands at an alarming 21 percent, the highest of all age groups in the United States. Every day 17 older individuals kill themselves.
Given such statistics, why are millions of our nation's elderly deprived of adequate mental health care? There are numerous factors accounting for this apparent state of apathy and indifference towards the unmet mental health needs of the elderly.
Many elders resist treatment for depression and other disorders, as their association with mental illness is based on images frequently propagated by the mass media and popular culture. Very often, television and movie portrayals of characters labeled mentally ill are frightening and powerful sources of mental illness misinformation. For the older generation, movies like "The Snakepit" and "Psycho" have left lasting negative perceptions of people experiencing psychological distress. The media rarely produces dramas depicting people coping with feelings of depression or anxiety who are not violent, nor do they have any regular programming that provides basic mental health information. It's therefore extremely important to have alternative TV programming that helps to re-educate people about what mental illness is and how it can be effectively treated.
Myths and misperceptions (ageism) about older people by the media, the public, and professional health and mental health providers have also affected mental health service delivery to elders. For administrators confronted with budgetary restraints, it has too often been the older population that has been cast aside, on the basis that they are too old to benefit from services. It would stand to reason that a society that places such great emphasis on youth and the importance of looking young does not lend enthusiastic support to better mental health care for the geriatric population.
Primary Care Physicians
Generally, the first person elders turn to for help with problems that require mental health treatment is their primary care physician. Many of these physicians have limited training in the care and management of geriatric patients. This makes the current lack of adequate mental health care particularly insidious because neither the elderly person nor the health care provider may recognize the symptoms. In no other age group is the combination and interrelationship of physical, social, and economic problems as significant as with the elderly. Elders tend to assume that complaints such as sleep disturbances, changes in appetite, and mood differences are related to physical problems. This tendency is reinforced by physicians, who often attribute symptoms to the aging process. Medical practice today does not usually allocate time for the detailed medical and social history that would encourage a more accurate diagnosis.
A 1990 study of elderly suicides in the Chicago area found that 20 percent of the suicide victims had seen their primary care physicians within 24 hours of their suicide, 41 percent within seven days, 84 percent within 30 days. This data greatly underscores the importance of early detection by health professionals and caregivers.
Practices and policies pertaining to the organization of elderly service delivery have not been based on actual experiential data, but on the attitudes and assumed efficiency of planners and funders in the private and public sectors. An illustration of this approach is the assumption that older consumers will self-refer to community mental health centers (CMHCs) for help with psychiatric disorders. In most instances, older adults do not appear at a CMHC unless they are brought by a relative or there is an acute crisis that requires an emergency visit. Even on those visits, few CMHCs have staff members that are responsive or knowledgeable about the special needs of this population.
At the state and local level, there is a question as to which service organization - the county aging agency or the county mental health system - is responsible for the mental health care of the elderly. Conflicting priorities led each system to focus on what they regard as their primary functions rather than addressing collaborative programs and strategies. In recent years, the aging agencies have been more concerned with long-term care while the mental health systems in many states have focused on developing programs for the seriously and persistently mentally ill.
A conundrum for advocates requesting additional mental health funding is the response from state funders that there is no point in additional allocations since they believe the elderly don't take advantage of the services already available. It is difficult to convince the people in control of the purse strings that the reason existing services aren't more frequently used is that the programs are not responsive to the needs of older consumers in the first place.
Service Integration: Is it An Impossible Dream?
The lack of coordinated, comprehensive health care has a negative impact on all age groups in the United States. For older adults who tend to have multiple needs, these health systems are highly fragmented and a bewildering source of patient confusion. Many elders withdraw from service feeling overwhelmed by the long waits and complex procedures.
Connections between primary care and social services are limited as are links with primary care and mental health services for older adults. Although there is unanimous agreement about the value of communication and of streamlined intake procedures, most agencies continue to function in isolation from one other. A big reason for this is the limited and parallel funding the agencies receive, which does not encourage the sharing of resources. As a result, many service organizations are deeply concerned about maintaining their autonomy and their funding - attitudes which do not foster inter-agency collaboration.
CMHCs in most areas of the country have devoted their resources to serving children and seriously mentally ill young populations. These centers have not been well integrated with social service agencies or with the network of primary care providers that are so important to older consumers.
There is a large disparity in Medicare and Medicaid reimbursement between psychiatric care and medical care. This has deterred many prospective psychiatrists, social workers, and psychologists from considering careers in geriatric mental health. Since its enactment in 1985, Medicare has specifically limited reimbursement to all the disciplines engaged in treating older adults. Not only are professionals reimbursed at lower rates, but co-payments for consumers are higher than for standard medical care. This is another drawback for older persons considering mental health treatment. Despite pressure from national professional organizations, there has been no significant improvement in this area from the Health Care Finance Corporation (HCFA),the agency that administers the Medicare program.
Lack of Organized Support
In contrast to the activities of groups such as the Alliance for the Mentally Ill (AMI), the National Mental Health Association, Disabled Americans, and Developmentally Disabled Children, there has been very little national attention directed to the quality and quantity of mental health services available to the nation's elders. Attempts to organize older people struggling with psychiatric disorders combined with physical impairments have met with minimal success. Local attempts to engage adult sons and daughters have not generated positive results.
Does the absence of organized concern suggest indifference to the mental health needs of elders? There is no one reason why older people with mental health problems have been overlooked and underserved. If funds were available, a public health education campaign to sensitize legislators and the general public might be a positive initial step.
t this stage in the development of managed care, it is difficult to determine whether Medicare HMOs will be a friend or foe to older members. With strong encouragement from Health Care Finance Corporation (HCFA), Medicare beneficiaries are joining HMOs at the rate of 80,00O members a month. The most common arrangement for all managed mental health care is for HMOs to contract with other behavioral health companies to provide the missing mental health component.
Despite the rapid increase in subscribers, mental health advocates are concerned that with the so-called carve out for mental health care, there may be even greater coordination problems for elderly consumers who have complicated physical and mental disorders. To date, HMOs have not demonstrated much interest in developing long term care services - essential for the well being of elders - as such services are more costly than short-term programs. Although preventive health is used as a marketing strategy, reports indicate that few of the 600 plans have made more than token efforts in this direction. Information about the exact number of physicians and other staff with geriatric training that are employed at HMOs is not available at this time.
Despite their glaring weaknesses in this regard, the HMOs remain an attractive option to the elderly because of the elimination of the costs for supplementary Medicare insurance and the various additional benefits - the reimbursement for glasses and prescriptions, for example - that many HMOs offer.
A Positive Perspective
While many of these barriers continue to restrict improvement and expansion of elderly mental health services, there are innovative programs that are either currently operational or under consideration in several states. There is still a good deal to be learned about interventions to better ease the psychic distress of older Americans, but there are programs that have used innovative ideas to achieve a level of success. Some of these successful programs have initiated or implemented one or more of the following:
- Outreach efforts to locate and identify older persons who are depressed and provide care relevant to their needs.
- Mobile programs with staffs that treat consumers in their own homes. Treatment in familiar surroundings reduces the fear of stigma.
- Effective treatment for elderly depression. Treating elders has been found to be just as effective as treating young adults and middle-aged people; supportive therapy and drug treatment can be safely administered with beneficial results.
- Coalitions of staff members, statewide and local, associated with mental health and aging networks.
- Meetings with state mental health departments to ask that older people be officially designated as a special population with unique needs.
- Meetings with state legislators or their aides to brief them about the unmet mental health needs of their constituencies.
- Training sessions conducted by staffs of aging and mental health agencies so each can have a better understanding of the services and limitations of organizations serving elders.
Trudy Persky, M.S.W., A.C.S.W., has had a four-decade career in human services, including 12 years as Project Director for Mental Health and Aging in the Philadelphia Office of Mental Health. She is now a consultant on mental health and aging issues.