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MENTAL HEALTH AND THE ELDERLY POSITION STATEMENT

*Last Updated January 1, 1993*

BACKGROUND

Mental illness is an important contributing factor to the disease burdens of the elderly. While the elderly do not appear to suffer a disproportionate share of most classifiable mental illnesses (depression or schizophrenia, for example), they do have a much higher prevalence of dementing illnesses such as Alzheimer's disease and are subject to high rates of interpersonal losses. Despite substantial rates of morbidity, the proportion of elderly persons recognized as impaired and who actually receive adequate treatment is markedly lower than in younger groups. This under-provision of services persists despite the fact that treatment of mental illnesses such as depression or paranoia in the elderly has been shown to be as effective as treatment in younger groups. Undertreatment of mental illness in the elderly appears to be a significant factor in the high suicide rate among elderly men, as well as in the premature or inappropriate placement of elderly persons in nursing homes.

Research on mental illness in the elderly has been ignored and neglected until very recently. Even with the attention that has been given to the existence of large numbers of patients with Alzheimer's disease, funding for research in comparison to the frequency and devastating nature of mental illness in the elderly remains inadequate.

POSITIONS

1. The severe restrictions on Medicare reimbursement for mental health services should be eliminated. Reimbursement for mental health services provided in non-hospital based, outpatient settings, including physicians' offices, home visits, outreach and case-finding programs, nursing homes, group residences, and community centers for the elderly, are especially critical.

Rationale: Significant barriers exist for the elderly in accessing and utilizing mental health services. Coverage under Medicare is inadequate and serves to further the myth that mental illness in the elderly is both to be expected and not responsive to treatment. A number of studies have shown that when mental health services are severely restricted, the result is higher costs in terms of hospitalization and overutilization of general medical visits. More important, current financing of mental health care reflects neither the pharmacologic and neurologic/biologic advances in psychiatric care nor that treatment in elderly persons can be just as successful as treatment in young persons.

2. The National Institute of Mental Health (NIMH) should continue to fund at adequate levels the development of training programs in interdisciplinary mental health care for the elderly that includes the disciplines of medicine, psychiatry, psychology, psychiatric nursing, and clinical social work. Training programs need to recognize that most mental health care takes place in the primary care setting.

Rationale: Most community surveys suggest that 1% or fewer elderly persons in the community receive psychiatric care. The elderly remain underserved by mental health providers, as shown by the following data.

Only 4% of community mental health center patients are over 65.

Fewer than 4% of the patients seen by private practitioners are elderly.

Less than 1.5% of all community-based mental health care goes to the elderly.

Older adults with psychiatric disorders frequently seek health care services in primary care settings, where the detection and management of this morbidity may be less than optimal. Given this situation, interdisciplinary mental health care training should receive high priority.

3. There should be immediate expansion of research programs funded by the NIMH and other agencies on the etiology and treatment of anxiety and depressive disorders, paranoia, the dementing disorders, and other behavioral disorders affecting elderly patients.

Rationale: Mental illnesses, including depression, paranoia, and dementias, such as Alzheimer's disease, are clearly among the most physically, emotionally, and economically devastating illnesses that commonly affect elderly persons. By some accounts, over $15 billion a year are spent on the care of victims of dementias alone. The financial and emotional burden placed on caretakers and family members of those elderly persons with mental illness is often overwhelming. Research on the epidemiology, etiology, pathophysiology, and effective treatment of mental illness in the elderly is critical to finding ways to ameliorate or prevent these illnesses.

Developed by the AGS Public Policy Committee and approved May 1987 by the AGS Board of Directors. Reviewed November 1990. Reviewed April 1993. The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.