MENTAL HEALTH SERVICES

The mental health needs of older Americans are a matter of increasing attention, a fact reflected in the growing number of services available since 1975. Even so, the mental health needs of older adults are poorly understood, mental health services are fragmented, and existing services are underutilized. Consequently the older population is especially vulnerable to preventable outcomes: related physical health problems, social isolation, risk of alcohol or medication misuse or abuse, a high rate of suicide, and a reduced quality of life.

As in any discussion about the older population, it is first important to recognize the wide age range and considerable diversity of the category of people we call "old." Conventionally, age sixty or sixty-five-plus has been used to mark entry into old age or older adulthood. A 1999 report on mental health and aging from the U.S. Surgeon General classifies "older adults" as the population age fifty-five and older, a categorization that includes centenarians, their children, and many of their grandchildren. Significant variability in physical health and mental health exists within and across age groups from the young old to the oldest old. The older population also is increasingly ethnically diverse; the minority share of the older population is projected to grow significantly, and the Latino population is expected to outnumber the African-American population by 2010 (Kart and Kinney). The heterogeneity of the older population has significant implications for the way mental health services are planned and implemented.

Epidemiology of mental disorders in late life

It is also important to understand age/ generational differences in mental disorder prevalence, risks, and needs, all of which are difficult to measure for several reasons. First, definitions of mental health, mental illness, and mental disorder are ambiguous and the terms are used loosely. Second, ageist assumptions about emotional and mental capacity in late life lead to confusion of mental disorders with "normal aging." Third, determining the incidence and prevalence of mental disorders is difficult when indicators are somewhat arbitrary and when people have biases against seeking treatment; needs in these cases remain hidden. Fourth, mental disorders in late life may mimic or mask other problems, particularly physical illnesses or the effects of medications. Fifth, cultural and/or generational differences may affect the identification and/or reporting of disorders. Sixth, distinctions between community- and institution-dwelling populations must be made when studying risks and needs, particularly in the eighty-five-plus age group; 20 percent of them live in nursing homes, and nearly 60 percent of those are affected by at least one mental disorder (including dementia) (Strahan and Burns). And finally, distinctions must be made between chronic and acute, mild and severe, and early- and late-onset disorders. These conceptual and measurement challenges inevitably affect the provision and delivery of mental health services.

Older and younger adults compared

The most reliable studies suggest that when dementia is excluded from the mental health profile, the older population appears to fare slightly better, or at least no worse, than younger cohorts in the prevalence of mental disorders. In some sense this is remarkable, given that older adults are more vulnerable to known mental health risk factors, such as physical illness, poor nutrition, social isolation, bereavement, and financial insecurity. The U.S. Surgeon General reports that 21 percent of adults age eighteen to fifty-four and nearly 20 percent of older adults have a diagnosable mental disorder, excluding dementia, in any given one-year period. Age-associated dementia, such as Alzheimer's disease, is a significant threat to the quality of life of older adults, and although its manifestations may include depression, anxiety, paranoia, behavior problems, and even psychosis, dementia is more often studied and treated as a medical, not a mental, illness. Mental disorders conventionally addressed through mental health services include anxiety, depression, schizophrenia, and adjustment disorders.

Although the prevalence of mental disorders in the older population is similar to that in the younger adult population, the unique effects of these disorders on older adults represent correspondingly unique challenges for mental health treatment and services. Some of these challenges are closely associated with the epidemiological issues identified above. In general, older adults with mental disorders have high rates of coexisting and mutually complicating physical illnesses; are vulnerable to the complications of the use of multiple medications; are more likely to become malnourished; are at special risk of social isolation and loss of social supports; have significantly higher suicide rates; and are especially vulnerable to loss of autonomy.

Early- vs. late-onset disorders

Many older adults are survivors of chronic, lifelong mental disorders, such as schizophrenia, bipolar (manic-depressive) disorder, or chronic major depression. These adults are more likely to enter old age with irregular work histories, legal and/or financial problems, impaired family relationships, substance abuse, and physical health problems. Such individuals are likely to be known and served by a system of mental health services throughout their adulthood. Other older adults experience the first onset of disorder late in life. Late-onset disorders can be destabilizing to individuals and families. Service needs and issues are different for early- and late-onset disorders.

Treatment and services

Older adults' mental health needs are identifiable and treatable. Effective interventions include individual and group psychotherapy; psychoactive medications; support groups, including support for family caregivers; hospitalization; electric shock therapy; family counseling; pastoral counseling; special therapies such as art, pet, and music therapies; community support services; and stress management and other skills training. Services are provided in a variety of settings, including, but not limited to, private clinical practices, community mental health centers, adult day care, group homes, foster care, nursing homes, general hospitals, psychiatric hospitals, and state hospitals.

There is no comprehensive service system for older adults with mental disorders. Older adults needing mental health services must depend on multiple care systems that are not well integrated to meet their complex needs: the aging network, the health care system, and the mental health system. Mental health interventions may be provided through one or any combination of these systems, through both the public and the private sector. Public sector mental health services are historically state-directed, although funding through Medicare, Medicaid, and block grants has increased the federal role since the 1960s. Older adult mental health programs and services vary in level and type across states. Some states have aging-specific services, while others do not specialize. State and nationwide mental health and aging coalitions, a phenomenon of the 1990s, promise improved coordination of care.

The primary care physician is a commonly utilized point of entry and treatment resource for older adults experiencing mental health problems, especially of the late-onset type. This is explained in part by the fact that mental health symptoms of older adults are likely to be linked to somatic symptoms, such as weight loss, insomnia, or shortness of breath. It is also explained in part by the generations-old stigma associated with mental health treatment. Primary care practitioners are in a good position to treat interrelated physical and mental health conditions, but mental health-related training and experience of health professionals vary widely.

Special issues of nursing home residents

Approximately 5 percent of adults age sixty-five and over live in nursing homes (U.S. Bureau of the Census). The rate of mental disorder in this institutionalized population is high, and access to services is disturbingly low. Deinstitutionalization of state mental hospital patients in the 1960s and 1970s resulted in the reinstitutionalization, into nursing homes, of many elderly patients. Nursing homes became de facto mental health settings but lacked the capacity to provide appropriate care. Related nursing home reforms were instituted in the late 1980s and early 1990s. Although improvements in care were achieved, studies measuring the effects of these reforms have confirmed, without exception, a continuing problem with low mental health treatment and service utilization rates among nursing home residents (Smyer and Qualls).

Access to services

The older population underutilizes mental health services. Older adults represent nearly 13 percent of the U.S. population but account for only approximately 6 percent of those served by community mental health centers and only 5 percent of the clinical hours of psychiatrists (Colenda and van Dooren). Use of mental health services is affected by availability, appropriateness, eligibility, and affordability of services. Mental health services may be available, but not appropriate to the lifestyles, physical capacities, and social attitudes of older adults. Ethnic minorities are especially underserved, in part due to language and/or other cultural barriers. Older adults living in rural or inner-city areas are more likely to be isolated from mental health services.

Mental health coverage by Medicare, Medicaid, and private insurance is generally more limited than coverage for other health care services. A national movement to improve parity, or equality, in mental health coverage led to federal legislation (the Mental Health Parity Act of 1996), and ultimately to expanded Medicare and private insurance coverage. At the turn of the twenty-first century, continuing growth and changes in the managed care industry make the future of mental health care uncertain. The effects of managed care on mental health service access, quality, and outcomes are being studied. Meanwhile, an aging, expanding, and increasingly diverse older population will create new demands for mental health services.

Kathryn B. McGrew

See also Dementia; Depression; Geriatric Psychiatry; Psychotherapy.

BIBLIOGRAPHY

Colenda, C. C., and van Dooren, H. "Opportunities for Improving Community Mental Health Services for Elderly Persons." Hospital and Community Psychiatry 44 (1993): 531–533.

Fogel, B. S.; Furino, A.; and Gottlieb, G. L. Mental Health Policy for Older Americans: Protecting Minds at Risk. Washington, D.C.: American Psychiatric Association, 1990.

Kart, C. S., and Kinney, J. M. The Realities of Aging, 6th ed. Boston: Allyn and Bacon, 2001.

Smyer, M. A., and Qualls, S. H. Aging and Mental Health. Malden, Mass.: Blackwell Publishers, 1999.

Strahan, G. W., and Burns, B. J. "Mental Illness in Nursing Homes: United States, 1985." Vital Health Statistics Series 13, no. 105 (1991).

U.S. Bureau of the Census. Aging in the United States: Past, Present, and Future. July, 1997. Available from www.census.gov

U.S. Surgeon General. Mental Health: A Report of the Surgeon General. 1999. Available from www.surgeongeneral.gov

Zarit, S. H., and Zarit, J. M. Mental Disorders in Older Adults: Fundamentals of Assessment and Treatment. New York: Guilford Press, 1998.