Gary Kennedy, MD
Albert Einstein College of Medicine
Montefiore Hospital
"Often, when you work with older people you stumble into a moment of drama when you’re listening to them tell a story. It’s fine to read history in books, but to talk with someone who’s lived it is precious. That’s one of the joys of geriatric practice."
Dr. Kennedy has been interested in biology since he was a little boy. At the University of Austin, where he did his premed prerequisites, he majored in the subject and minored in German. Reading Freud in the original introduced Kennedy to psychology and the concept of the unconscious, which fanned an interest in the mind-body connection. An earlier experience had already created the spark: When Kennedy was in grade school, an aunt who earned her living as an astrologer had given him a textbook about psychosomatic medicine. He was fascinated by what he read. After earning his degree and completing his internship and residency at the University of Texas Medical School at San Antonio, he headed to Montefiore Medical Center, in the Bronx, New York, for a residency in psychosomatic medicine.
"Psychosomatic medicine is what led me to geriatric psychiatry," says Kennedy, now Professor of Psychiatry and Behavioral Science at Albert Einstein College of Medicine and Director of the Division of Geriatric Psychiatry and the Fellowship Training Program at Montefiore. "So, I guess you could say I was set up for a career in the field."
Dr. Kennedy has done significant research investigating ways to improve the treatment of depression in older adults and examining the relationship between depression and cognitive impairment. In addition to his research, teaching and mentoring work, he also does clinical work with older patients. Addressing older adults' mental health needs is challenging, he says, and uniquely satisfying.
Q: It was the research you did while completing your fellowship in psychosomatic research that prompted you to do a second residency in geriatric psychiatry—is that right?
A: Yes. I came to New York to do a fellowship in psychosomatic psychiatry and I caught the research bug here. While I enjoy making a formal review of other investigators' data, there's nothing like having your own original data to exhibit. I first got involved in arrhythmia research, which exposed me to a lot of older adults with cognitive impairment. I found I enjoyed working with these patients despite their impairment. The work involved a whole field of fascinating influences—connections among the brain, heart, mind and emotions. I've always been interested in working at the interfaces, the boundaries where there are multiple influences. The bridge from psychosomatic medicine to geriatric psychiatry was via the heart and cognition. So there was the intellectual side. And part of it, I have to say, was ambition—geriatric psychiatry was a promising career path.
Q: Could you talk about how clinical work complements the other work you do? What mental health problems are most common among your patients?
A: I do a mix of research, teaching and clinical work. The usual recipe for success is to focus on one of the three, but in geriatrics we try to do all three and I think I've had fair success with that. I see a small number of patients, maybe 10 hours a week. My patients' problems include depression, anxiety, personality issues, life circumstances and, of course, dementia. About 10% of my caseload is house calls so I'm out in the community at least once a week. It's time consuming and Medicare is not remunerative, but I don't do it for income. I do it to keep my clinical skills alive. If I'm teaching how to do house calls, it's important that I do house calls as well.
Q: You've said you also find the clinical work very satisfying...
A: Absolutely. Often, when you work with older people you stumble into a moment of drama when you're listening to them tell a story. It's fine to read history in books, but to talk with someone who's lived it is precious. That's one of the joys of geriatric practice. Sometimes the stories are intriguing, even humorous, more often they're tragic.
I'll share an anecdote: Early in my career I was interviewing an older man with terminal metastatic cancer. He wasn't forthcoming until I started checking his cognitive capacity. I asked him to count backward from 100 by 7s and he looked me in the eye with a slight grin and sprinted through the subtractions. He was an automatic calculator. He saw the puzzlement on my face, opened up and told me he had been a numbers runner in the Bronx! He was good, he said, because he kept everyone's bets in his head.
I take care of a number of Holocaust survivors, and their stories are heartbreaking but also inspiring. Another reward of this work is that you see this natural resiliency that is the antidote to despair about the decay of the body that occurs over time. It's sometimes called "wisdom" or the sense of emotional and personal integrity that endures even though the body declines.
Q: How successful is mental health treatment for older adults?
A: It's very successful, if the goal is to make things better. If the goal is to cure, then there's a lot of frustration for you, for patients, and for families. A realistic perspective often means a trial of something: Let's try an intervention that the literature indicates can be beneficial; let's apply it and see how it works.
For depression, a combination of medication and talk therapy is often most helpful. But some older adults would rather just have talk therapy and the response rates with that approach aren't bad either. If there's recurrent depression, suicidal ideation, or complicating issues, or there's greater severity of depression, however, then both meds and psychotherapy are usually indicated.
I worked with a 79-year-old woman whose recurrent depression required electroconvulsive therapy. Our first session occurred within a week of her last convulsive treatment. She was obviously confused and I found myself demoralized at the prospect of her future decline, due to previously undiagnosed dementia. But within weeks of starting therapy, which also included medication, she cleared completely and began to volunteer at a museum in Manhattan which required her to ride an express bus from the Bronx twice a week. Ultimately she moved to Manhattan to be closer to her new friends from the museum who, like her, enjoy opera, ballet, and concerts. She has had minor episodes of depression since then but I am convinced that the medication, psychotherapy and social engagement have prevented a full recurrence. She continues to keep me up-to-date on all the high profile performances I haven't the time to attend!
So people like me say, "Depression is eminently treatable in late life." But it's not so easily treatable. It's a challenge. You need to work with the patient and the family, with the primary care physician and you need to get the meds up more rapidly -- start low, go slow but don't be reluctant to make a change if the first choice fails.
Q: Depression seems to be fairly common in older adults with dementia. How successful is treatment in these cases and can psychotherapy help?
A: In patients with dementia, depression can effectively be treated with medications and in some cases with psychotherapy. Just because a person has dementia doesn't mean they can't benefit from psychotherapy. Obviously, someone with advanced dementia is no longer verbal, but that doesn't mean, in the early phases, the person can't respond to psychotherapy. Again, often the approach is to think of it as a trial.
There are other things that are also helpful, such as exercise to distract the person with dementia, so he or she doesn't dwell on a particular problem.
Q: Is this likely to improve in the near future? Is there any reason for optimism?
A: There's substantial evidence for both psychotherapy and medication across the whole range of late life mental disorders. The evidence base is startling for how impressive it is. There have also been two or three national campaigns to raise awareness of depression and dementia. If we mobilize the public on depression care the way we've mobilized the public for dementia care, I think you'll see significant changes in policy.
A substantial minority of National Institute of Aging research policy money goes to dementia. If a substantial minority of the public health money from the National Institute on Mental Health went to older adult mental illness research, we'd be much better off. That would also attract many more people to the field.
I am optimistic. I think the baby boomers—part of "Prozac Nation"—are sensitized to this problem and they'll demand better mental health services. When they realize how limited these services are to their parents, I think we'll see mounting social concern. Of course, what we fail to fix for our parents, we'll face ourselves.
