Mental Disorders and AgingMental Disorders and AgingAn Emerging Public Health An Emerging Public Health

Crisis in the New Millennium?Crisis in the New Millennium?

Stephen J. Bartels, M.D., M.S.Director, Aging Services Research

NH-Dartmouth Psychiatric

Research Center

Mental Disorders and AgingMental Disorders and Aging

– Impact of Problem: 4 Facts to Guide Public Policy

– Examples of Model Programs

– Vision and Values for Improving Services

– Suggested Directions

Mental Disorders of Aging: Mental Disorders of Aging: 4 Facts To Guide Public Policy4 Facts To Guide Public Policy

1) Dramatic recent and projected growth

2) Major direct and indirect impact on health outcomes, service use and costs

3) We know treatment works, but effective services are not reaching those in need

4) An alarming under-investment in knowledge dissemination, service development, and research to meet future need

Impact of the ProblemImpact of the Problem

Projected Growth In Older Projected Growth In Older Adults With Mental IllnessAdults With Mental Illness

Population aged 65 and older will increase from 20 million in 1970 to 69.4 million in 2030.

Older adults with mental illness will increase from 4 million in 1970 to 15 million in 2030.

(Jeste, et al., 1999; www.census.gov)

Aging In AmericaAging In America

12.5% 12.7% 13.2%

16.5%

20.0% 20.5%

3.8%2.5%2.1%1.9%1.6%1.2%

0%

5%

10%

15%

20%

25%

(248.8 Million)1990

(275.3 Million)2000

(299.9 Million)2010

324.9 Million)2020

(351.1 Million)2030

(377.4 Million)2040

Age 65+ Age 85+

www.census.gov

Estimated Prevalence of Major Estimated Prevalence of Major Psychiatric Disorders by Age GroupPsychiatric Disorders by Age Group

7

8

9

10

11

12

13

14

15

16

2000 2010 2020 2030

18-29 30-44 45-64 65 >

Jeste, Alexopoulus, Bartels, et al., 1999

Prevalence of Mental Prevalence of Mental Disorders Age 65+Disorders Age 65+

Psychiatric 16.3%Dementia 10%Mental disorders: 26.3%

(including dementia)Psychiatric disorders 19.8%

based on prevalence of 30-40% of dementia complicated by depression, psychosis, or agitation.

Jeste, et al., 1999

Mental Disorders in Older Mental Disorders in Older Adults:Adults: The Silent Epidemic The Silent Epidemic

Alzheimer’s and other memory disorders (30-40% complicated by depression or psychosis)

Depression, anxiety disorders, severe mental illness, alcohol abuse

Suicide: highest rate: age 75+

Psychiatric Illness in Older Persons Psychiatric Illness in Older Persons as a Public Health Problem: as a Public Health Problem: Impact on Health OutcomesImpact on Health Outcomes

Worse outcomes– Hip fractures– Myocardial infarction– Cancer (Mossey 1990; Penninx et al. 2001; Evans 1999)

Increased mortality rates– Myocardial Infarction (Frasure-Smith 1993, 1995)

– Long term Care Residents (Katz 1989, Rovner 1991, Parmelee 1992; Ashby1991; Shah 1993, Samuels 1997)

Depression Associated with Depression Associated with Worse Health OutcomesWorse Health Outcomes

Depression in CancerDepression in Cancer

Increased HospitalizationPoorer physical function Poorer quality lifeWorse pain control

(Evans 1999)

Depression in Older Adults and Depression in Older Adults and Health Care Costs Health Care Costs

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

0 (n=859) 1-2 (n=616) 3-5 (n=659) 6-16 (n=423)

Levels of Chronic Disease Score

None CES-D<8Moderate CES-D=8-15Severe CES-D>16

Unutzer, et al., 1997; JAMA

Suicide in Older AdultsSuicide in Older Adults

65+: highest suicide rate of any age group85+: 2X the national average (CDC 1999)

Peak suicide rates: – Suicide rate goes up continuously for men – Peaks at midlife for women, then declines

1/3 of older men saw their primary care physician in the week before completing suicide; 70% within the prior month

Suicide Rate by Age Per 100,000Suicide Rate by Age Per 100,000

0%

5%

10%

15%

20%

25%

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+Age

Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hoyert, 1999)

Summary of FindingsSummary of Findings

Depression is common in medical disorders among older patients

Associated with worse health outcomes

Greater use and costs of medicationsGreater use of health services

– medical outpatient visits, emergency visits, and hospitalizations

Older Adults with Older Adults with Severe Mental IllnessSevere Mental Illness

Monthly Per Person Costs by Age:Monthly Per Person Costs by Age: Severe Mental Illness Severe Mental Illness

$0

$1,000

$2,000

$3,000

$4,000

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85-94 95+

Age Groups

Medicaid+Medicare Medicaid Medicare

New Hampshire Total Monthly New Hampshire Total Monthly Costs Per Person Over Age 65Costs Per Person Over Age 65

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

Schizo

phrenia

Alzheim

er's

Demen

tiaCer

ebro

vasc

ular

Depre

ssio

nH

eart

Fai

lure

COPD

Cardia

cDys

rhym

ias

Oste

oart

hrosis

Diabe

tes

Hyp

erte

nsion

Medicaid Medicare

Severe Mental Illness in Severe Mental Illness in Older AdultsOlder Adults

Rapid growth projected (Jeste, et al., 1999)

Lack of community living skills associated with nursing home and high cost services

(Bartels et al., 1997, 1999)

Lack of Rehabilitative Interventions

High Medical Comorbidity (Vieweg, 1995;Goldman, 1999)

Poor Health Care and Increased Mortality(Druss, 2001)

Falling Through the Falling Through the CracksCracks

Community Mental Health Services• Under-serve older persons

• Lack staff trained to address medical needs

• Often lack age-appropriate services

Principal Providers: Primary Care and Long-term

Care Medicare

• No general outpatient prescription drug coverage & lack of mental health parity

Unmet Need for Unmet Need for Community TreatmentCommunity Treatment

Less than 3% of older adults receive outpatient mental health treatment by specialty mental health providers

– (Olfson et al, 1996).

Only 1/3 of older persons who live in the community and who need mental health services receive them

– (Shapiro et al, 1986).

Nursing Homes: The Primary Nursing Homes: The Primary Provider of Institution-Based Provider of Institution-Based Care for Older Persons with Care for Older Persons with Mental DisordersMental Disorders

65-80% of Nursing Home Residents-A Diagnosable Mental Disorder

Among the Most Common Disorders– Dementia – Depression– Anxiety Disorders and Psychotic Disorders

(Burns & Taube, 1990, 1991, Rovner et al., 1990)

Unmet Need for Unmet Need for Mental Health Services Mental Health Services

in Nursing Homesin Nursing Homes

Over one month: 4.5% of mentally ill nursing home residents received mental health services (Burns et al., 1993)

Over one year: 19% in need of mental health services receive them. – Least likely: Oldest and most physically

impaired (Shea et al., Smyer et al., 1994)

Fragmentation of the Fragmentation of the Service Delivery System Service Delivery System

for Older Personsfor Older Persons Primary care Specialty mental health Aging network services Home care Nursing Homes Assisted Living Family caregivers

“The advantages of a decisive shift away from mental hospitals and nursing homes to treatment in community-based settings today are in jeopardy of being undermined by fragmentation and insufficient availability of services.”

(Admin. on Aging, 2000)

Poor Quality of Care for Poor Quality of Care for Older Persons with Mental Older Persons with Mental DisordersDisorders

Increased risk for inappropriate medication treatment (Bartels, et al., 1997, 2002)

> 1 in 5 older persons given an inappropriate prescription (Zhan, 2001)

Less likely to be treated with psychotherapy (Bartels, et al., 1997)

Lower quality of general health care and associated increased mortality (Druss, 2001)

Inadequate Workforce of Inadequate Workforce of Trained Geriatric Mental Trained Geriatric Mental

Health ProvidersHealth Providers

Current Workforce: 2,425 Geriatric Psychiatrists

200-700 Geriatric Psychologists

Estimated Current Need: 5,000 + of each specialty

Severe Nursing and Allied Health Care Provider Shortage

The Public Health CrisisThe Public Health Crisis

Dramatic growth in aging population– Major direct and indirect impact on health

service use and costs

Under-investment in Knowledge Dissemination, Service Development, & Research to Meet the Future Need

An Underinvestment in the An Underinvestment in the Service Infrastructure for Older Service Infrastructure for Older Adults Mental Health ServicesAdults Mental Health Services

Medicare Expenditures for Medicare Expenditures for Mental Health Services Mental Health Services

Total 1998 Medicare Health care Expenditures: 211.4 Billion

Total Mental Health Expenditures: 1.2 Billion (0.57%)

Outpatient Mental Health Expenditures:

718 Million (0.34%) CMS, 2001

An Underinvestment in the An Underinvestment in the Research Infrastructure Devoted Research Infrastructure Devoted

to Mental Health and Agingto Mental Health and Aging

Expenditures on NIMH Expenditures on NIMH Newly Funded GrantsNewly Funded Grants

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000Fiscal Year

Total NIMHGrants

AgingGrants

8% 7% 8% 8% 9% 6%

NIMH, 2001

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1995 2000 2010 2020 2030

Projected Prevalence & Research FundingProjected Prevalence & Research Funding

% of Total Expenditures on Aging NIMH Grants

Health Care Expenditures:

Age 65+ as Proportion of Total

Proportion of Population: Age 65+

Psychiatric Disorders: Ratio: age 65+/age 18-64(1990: 6.1 / 21.1 Million)(2030 : 15.2 / 36.5 Million)

Recognition of the problemRecognition of the problem

We know treatment works……..

But effective treatments are not getting to those in need

We Are Failing to Provide Effective We Are Failing to Provide Effective Treatments and Services to Those in NeedTreatments and Services to Those in Need

System Barriers: Fragmentation: A Need for Integrated Mental Health Services in Primary and Long-term Care

Training Barriers: The Limits of Traditional Educational Approaches in Changing Provider Behavior and Ageism

Financial Barriers: Including a Mismatch Between Covered Services and a Changing System of Long-term and Community-based Care

Consumer Barriers: Stigma and education

What Can Be Done to Improve What Can Be Done to Improve Access and the Quality of Care?Access and the Quality of Care?Examples of Promising ModelsExamples of Promising Models

We Know Treatment WorksWe Know Treatment Works

Systematic Reviews of the Highest Levels of Evidence for Geriatric Mental Health Interventions and Services:

26 Meta-analyses 8 Systematic evidence-based reviews 12 Expert consensus statements

“Evidence-based practices in geriatric mental health care”

Bartels SJ, Dums AR, Oxman TE, Schneider LS, Areán PA,

Alexopoulos GS, Jeste DV. Psychiatric Services, 53, 53:1419-1431, 2002

Evidence-based Evidence-based PracticesPractices

Mental health outreach services Integrated service delivery in primary care Mental health consultation and treatment teams

in long-term care Family/caregiver support interventions Psychological and pharmacological treatments

Strategy: Implementation Toolkits

Draper, 2000; Unützer, et al., 2001; Schulberg, et al., 2001; Bartels et al., 2002, 2003; Sorenson, et al., 2002;

Integrated mental healthIntegrated mental health in primary care in primary care

PRISMe (SAMHSA)PROSPECT (NIMH)IMPACT (Hartford Foundation)

– Current studies which will inform researchers, clinicians, and policy makers on optimal models for integrating mental health in primary care for older persons.

Outreach programsOutreach programs

“Gatekeeper” Model– Trains community members to identify and

refer community-dwelling older adults who may need mental health services

– Effective at identifying isolated elderly, who received no formal mental health services

Florio & Raschko, 1998

Outreach programsOutreach programs Psychogeriatric Assessment and Treatment in City

Housing (PATCH) program. – Serving Older Persons in Baltimore Public Housing

3 elements– Train indigenous building workers (i.e.,managers, janitors,) to

identify those at risk – Identification and referral to a psychiatric nurse – Psychiatric evaluation/treatment in the residents home

Effective in reducing psychiatric symptomsRabins, et al., 2000

Caregiver Support InterventionsCaregiver Support Interventions

Delays placement in nursing homes for persons with dementia from 166 days to 19.9 months (Mittleman et al., 1995; Moniz-Cook et al., 1998;

Riordan & Bennett, 1998; Roberts et al., 1999)

Improved Caregiver Mental Health -Decreased incidence and severity of depression -Improved health (e.g., lowered blood pressure)-Improved stress management

Sorensen, Pinquart, Duberstein, 2002

Peer Support and Peer Support and Faith-based ServicesFaith-based Services

Peer support groups for older persons with losses improve mental health outcomes

(Lieberman & Videka-Sherman 1986)

Peer support groups may be more acceptable to older persons and allow participants to be recipients and providers of assistance

(Schneider & Kropf, 1992)

The HOPES Study: The HOPES Study: HHelping elping OOlder lder PPeople with Severe Mental Illness eople with Severe Mental Illness

EExperience xperience SSuccessuccess

Rehabilitation: – Skills training groups on community living

skills, social skills, and health maintenance skills

Health Care Management: – Nurse case manager monitoring,

facilitation, and coordination of primary/preventative health care, health education

Bartels et al., Supported by NIMH

A Sourcebook Describing Locally A Sourcebook Describing Locally Developed Model ProgramsDeveloped Model Programs

“Promoting Older Adult Health through Aging Network Partnerships”

Education and preventionOutreachScreening, referral, intervention, and

treatmentService improvement through coalitions

and teams

SAMHSA & NCOA (2002). Promoting Older Adult Health: Aging Network Partnerships to Address Medication, Alcohol, and Mental Health Problems (DHHS Publication No. MS 02-3628).

Vision and Values for Vision and Values for Improving ServicesImproving Services

Enhance independent functioning

Aging in place Quality of life Home and community-

based alternatives Integrated care Quality medical care Rehabilitation Recovery

Access to mental health services (parity) and needed medications (drug benefit)

Aging with dignity Support of meaningful

activities Community integration The "right" to evidence-

based treatments

Improving Mental Health Improving Mental Health Services for Older Americans Services for Older Americans

Priority Policy Areas for Priority Policy Areas for Mental Health and AgingMental Health and Aging

Medicare Mental Health Parity Medicare Mental Health Parity and Prescription Drug Benefitand Prescription Drug Benefit

Urge federal legislative action on Medicare mental health parity and a Medicare Pharmacy benefit

Integrated Mental Health Services Integrated Mental Health Services in Primary and Long-term Carein Primary and Long-term Care

Waivers supporting integrated mental health in primary and long-term care

Extend Medicare-covered care planing and case management to community settings

Multidisciplinary Outreach and Multidisciplinary Outreach and Wraparound ServicesWraparound Services

Waivers supporting multidisciplinary community outreach and wrap-around service teams to prevent nursing home placement

Implementation of Evidence-Implementation of Evidence-based Mental Health Practicesbased Mental Health Practices

A National Initiative to Disseminate and Implement Evidence-based Mental Health Practices for Older Persons (SAMHSA, NIMH, AHRQ)

Reduce Stigma and Other Reduce Stigma and Other Barriers to Mental Health CareBarriers to Mental Health Care

HHS Public Education Campaign: Reduce Stigma, Prevent Suicide, Identify and Treat Late Life Depression

Develop Culturally Competent Services

Increase workforce with training Increase workforce with training in treatment of older personsin treatment of older persons

Federal Study of Geriatric Health Workforce Needs

Nurse Training Programs

Loan repayment and Limit Exemption for Geriatric Residency Training Programs

Enhanced Caregiver Mental Enhanced Caregiver Mental Health and SupportHealth and Support

AOA-funded caregiver support services to include screening for depression and other mental disorders

Include mental health services as a priority for caregiver support services

PreventionPrevention

Prevention of late life depression, suicide, and alcohol and medication misuse as a priority for HHS and CDC prevention programs

Enhance Research Enhance Research on Mental on Mental Health and AgingHealth and Aging

Designate mental disorders of aging as a priority at NIMH, CMHS, CSAT, CSAP, AHRQ

Designate an office for oversight of mental disorders of aging research

Require federally funded grants to address inclusion of persons age 65 and older

“ The opportunity to address these critical challenges is before us. If we hesitate, our service delivery systems will be strained even further by the influx of aging baby boomers and by the needs of underserved older Americans.”

Administration on Aging, 2000

The Calling and the Opportunity

“Above all, now is the time to alleviate the suffering of older people with mental disorders and to prepare for the growing numbers of elders who may need mental health services.”

Administration on Aging, 2000

“The capacity of an individual with mental or behavioral problems to respond to mental health interventions knows no end-point in the life cycle.

Even serious mental disorders in later life can respond to clinical interventions and rehabilitation strategies aimed at preventing excess disability in affected individuals.”

C Everett Koop, Surgeon General’s Workshop Health Promotion and Aging, 1988