Committee members' affiliations
Dr. Koh is affiliated with the Department of Psychiatry, University of California, San Diego. Dr. Blank is with the Department of Psychiatry, Hartford Hospital/Institute of Living, Hartford, Connecticut. Dr. C. Cohen is with the Department of Psychiatry, State University of New York Downstate Medical School, Brooklyn. At the time of the study, Dr. G. Cohen was with the Department of Psychiatry, George Washington University School of Medicine, Washington, D.C. Dr. Faison is with the Department of Psychiatry, Medical University of South Carolina, Charleston. Dr. Kennedy is with the Department of Psychiatry, Albert Einstein College of Medicine, the Bronx, New York. Dr. Kyomen is with the Department of Psychiatry, Harvard Medical School, Belmont, Massachusetts. Dr. Liptzin is with the Department of Psychiatry, Tufts University School of Medicine, Springfield, Massachusetts. Dr. Meador is with the Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee. Dr. Rohrbaugh is with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut. Dr. Rusch is with the Department of Psychiatry, University of Wisconsin School of Medicine, Madison. Dr. Sakauye is with the Department of Psychiatry, University of Tennessee-Memphis School of Medicine, Memphis. Dr. Schultz is with the Department of Psychiatry, University of Iowa School of Medicine, Iowa City. Dr. Streim is with the Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia.
The landmark 1999 Surgeon General's report on mental health highlighted the future need for mental health services for the elderly: "As the life expectancy of Americans continues to extend, the sheer number of persons experiencing mental disorders of late life will expand, confronting our society with unprecedented challenges in organizing, financing, and delivering effective mental health services for this population" (1). However, it is unknown what the public's perception is regarding the availability of services to evaluate and treat the cognitive, emotional, and behavioral problems of older adults.
Editor's Note: This Open Forum is the third contribution to an occasional series in which the Group for the Advancement of Psychiatry (GAP) (www.ourgap.org) will present ideas to further the understanding of mental illness and improve access to care and quality of treatment for persons with mental disorders. Since its beginnings in the post-World War II era of providing modern psychiatric care, GAP has continued to be a think tank operating through its committee structure of national experts to present reports and position statements that are disseminated nationally and internationally.
The Committee on Aging of the Group for the Advancement of Psychiatry (GAP) explored methods to obtain such information in a cost-effective manner. A unique opportunity presented itself through the long-standing relationship between GAP and the advice columnist Jeanne Phillips, who publishes a daily column in U.S. newspapers under the name "Dear Abby." The column is the most widely syndicated in the world and receives more than 10,000 letters and e-mails per week (2).
In spring 2006 Ms. Phillips used her "Dear Abby" column to elicit thoughts from her readers regarding mental health problems in later life and services available for treating these problems. She wrote, "Dear Readers: A group of distinguished geriatric psychiatrists is interested in learning about the experiences of seniors in getting help for mental and emotional problems. (Geriatric psychiatrists are doctors who specialize in older patients.) They would welcome information such as how older people feel about mental health problems, where you seek help for them, what you feel needs to be done to improve services, and whether you'd like more mental health services than you are getting now. If you care to share this information, please direct your letters to: Dr. Gene Cohen, Center on Aging, Health and Humanities … P.S. If you would like to 'vent,' they're ready to hear it."
This Open Forum presents a summary of the responses without individually identifiable information. The project was determined to be exempt from review by the institutional review board at the George Washington University School of Medicine. The committee members systematically reviewed the letters and reached consensus in identifying their major themes. Responses were used to stimulate discussions and ideas for recommendations to improve mental health care to the aging population.
More than 800 replies were received in response to the request (250 coming via regular mail and more than 450 coming via e-mail). Respondents were either older adults with mental illness or their family members and friends. In many cases it could not be determined what the relationship was between the letter writer and the individual he or she was concerned about, so it was not possible to determine the percentage of respondents who were patients and caregivers. It was also not possible to determine the time period in which these responses were received or the relative percentage of letters on this topic compared with all letters that the column receives.
The letters revealed three major themes: problems with access to geriatric mental health care, inadequate recognition and detection of geriatric mental health problems by primary care physicians, and need for psychotherapy. These themes reflected ongoing concerns at every stage of the patient care continuum. We present these themes with excerpts from the letters and offer comments on possible solutions that the letters point toward. A more rigorous qualitative analysis was considered, but it was judged that such an analysis would not substantially change the themes that were identified.
Problems with access to geriatric mental health care
Overwhelmingly, the most pervasive concern cited by Dear Abby's readers was related to the difficulty older adults had in obtaining an initial visit with a mental health professional. One reader wrote, "Both my sister (age 72) and I (single, aged 67), who live together in an apartment and have no other kin, are aware that we both have mental health and emotional problems and, further, that we not only want but genuinely need some form of psychiatric treatment. You may also be interested to know how frustrated we feel about the lack of accessibility to medical buildings and the scarcity of psychiatric staff. And we absolutely feel that some type of biannually or annually required mental/medical analyzation should follow when our regular doctors prescribe psychiatric medications."
Others discussed the need for improved referral and care delivery systems, as reflected when one reader said, "I had great difficulty locating the services my parents needed. A person who is already experiencing mental and emotional problems finds it impossible to receive such services. There are services that are available, but it took real diligence, determination, and time to find them, and many of those programs are overwhelmed and just not available to many who need them." Such referral and care delivery systems can be created by utilizing and leveraging the Internet. Coordination between Internet-based systems and traditional listings will be more efficient and make services more accessible.
Respondents also recognized that medical comorbidities could interfere with and delay the treatment of mental illness. As one reader said, "Having to wait for the emotional problems to be treated until physical disabilities are treated first—the wait can be long."
Several respondents stated that they were acutely aware of the national shortage of mental health providers with specialized training to treat the older population. Others blamed the situation on economics. As one respondent said, "Someone mentioned to me that the reason most physicians don't go into this field is Medicare doesn't pay as well as most other insurances." In order to obtain needed treatment, an older adult on a fixed income might have to cover copayments and psychotherapy and medication expenses not covered by insurance.
Some mentioned logistical problems, such as transportation problems; caregivers often commented that transportation problems meant that they would have to drive their relatives to appointments and miss work. Others pointed out that going to a specialist meant getting to know yet another doctor and committing to even more appointments. This could become a practical challenge, especially if the patient was referred to different clinicians for medication management or psychotherapy. Potential solutions include providing psychotherapy and medication management in the same visit, improving transportation services, implementing telepsychiatry systems to provide care at home, and funding in-home mental health services for patients who are homebound.
One respondent gave advice on how to increase psychiatric services in rural and underserved areas: "A system for graduating therapists that [would place them in] areas that are underserved, especially with respect to specialty needs, such as geriatrics; or even a policy that encourages relocation to chronically underserved areas, such as is done for 'physical' physicians." Clearly, financial incentives to help with educational loans or to encourage those interested in the geriatrics field are needed.
Inadequate recognition and detection
Many older adults responded by noting that there was a lack of attention to mental health issues from their internist or family doctor. This problem contributed to their reluctance in talking about mental health problems and to a communication gap between them and their doctor.
One respondent said, "I think it would be extremely helpful if every doctor seeing an elderly patient would at least inquire a bit about symptoms of mental/emotional issues—like insomnia. My parents simply will not bring up these problems. They find them shameful and embarrassing. If a doctor brought it up, that might open the door to discussion." Even in primary care settings, simple incorporation of age-appropriate screening tools and measures will open doors to such discussions and help with mental health care. Continuing training to distinguish between normal aging and the pathological disease processes of later life is important.
"Their primary care physicians may give them antidepressants or other meds, but counseling is not usually recommended. I feel that a combination of counseling and medications is the most effective choice. Their physicians prescribe tranquilizers and sleeping pills at an alarming rate, which makes them more depressed and also more likely to fall and hurt themselves due to dizziness and disorientation," one respondent said. This points to a need for a more integrated model of mental health care in the primary care setting, such as the development of a patient-centered medical home, and expansion or consideration of novel programs, such as IMPACT (Improving Mood: Promoting Access to Collaborative Treatment for Late-Life Depression) (3) and PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) (4).
Several respondents stated a strong interest in having psychotherapy to explore solutions to problems associated with aging and disability and to help with interpersonal problems, such as grief and isolation. As one respondent said, "From our perspective it would be very helpful to have more short-term counseling and group therapy available to deal with depression and anxiety. There are times when both of us need to cry on the shoulder of a mental health professional, get some sound advice on how to deal with a particular problem."
Exclusive emphasis on psychopharmacology without offering "talk therapy" was described as dismissive and disrespectful. One respondent said, "As for improving mental health services, there needs to be more talk therapy before jumping on the mind-drug wagon."
There appeared to be a trend toward increased interest in psychotherapy by the current cohort of geriatric patients, compared with previous generations, and it seems likely that this will continue with the aging of the baby boomers. It will prove to be invaluable to promote widespread availability of evidence-based psychotherapies for older adults. Improvements in reimbursement rates for therapy will be needed to make it readily available.
It should be acknowledged that the responses reported here are not the results of a scientifically designed survey. They were not from a representative sample of people concerned with the mental health needs of older adults, but rather they were from people moved to write in response to Dear Abby's invitation. Their letters reflected a sense of helplessness in caring for those with emotional needs and problems in late life. Others took the time to "vent" about their specific difficult situations with the hope that improvements could be made.
What became evident as we read these hundreds of heartfelt letters from around the country was that the respondents seemed to be aware of mental health problems and were willing to write about them. It is not surprising that the letter writers had difficulty finding care for themselves or for a loved one. The writers knew that psychiatric problems should be addressed and could respond to the right treatment. But like the generations of older adults before them, they continued to face significant barriers in getting the appropriate care. These barriers ranged from insufficient insurance coverage for mental health care, to a delivery system more focused on dealing with general medical conditions, to a marked shortage of providers competent to provide mental health care to older adults. Although the respondents felt a deep frustration about these shortcomings, they also had a sense of hope that more progress could be made.
It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform. The Institute of Medicine published a monograph (5) on the geriatrics workforce, and a subsequent study has been requested on the geriatrics mental health workforce. The 2005 White House Conference on Aging (6,7) began this discussion, which should continue under the Obama administration. More information is needed on the effects of Medicare managed care on access to services (8), on ways to reduce the high rates of suicide among elderly people (9), and on improving the treatment of psychiatric problems in primary care (10). In addition to being the morally right thing to do, improved mental health services for the elderly may reduce overall health care utilization and improve the quality of life for this large and growing population.
The authors gratefully acknowledge the assistance of Jeanne Phillips, who asked the readers of "Dear Abby" to respond to her request for information and forwarded the letters for review and analysis. The authors are deeply grateful to the respondents. Their generous and frank comments were invaluable in the committee's work to provide best care for the elderly. The authors dedicate this Open Forum to the late Gene Cohen, M.D. He was the first director of the National Institute of Mental Health's Center on Mental Health and Aging and later director of the National Institute on Aging. This Open Forum was a result of his leadership of the GAP Committee on Aging over many years. He died after a long battle with cancer before this Open Forum was completed.
The authors report no competing interests.
1.Mental Health: A Report of the Surgeon General. Washington, DC, Department of Health and Human Services, US Public Health Service, 19992.About Dear Abby. Kansas City, Mo, uexpress. Available at www.uexpress.com/dearabby/bio.html3.Unützer J, Katon W, Callahan CM, et al: Depression treatment in a sample of 1,801 depressed older adults in primary care. Journal of the American Geriatrics Society 51:505—514, 20034.Raue PJ, Alexopoulos GS, Bruce ML, et al: The systematic assessment of depressed elderly primary care patients. International Journal of Geriatric Psychiatry 16:560—569, 20015.Institute of Medicine Committee on the Future Health Care Workforce for Older Americans: Retooling for an Aging America: Building the Health Care Workforce. Washington, DC, National Academies Press, 20086.Report of the 2005 White House Conference on Aging: The Booming Dynamics of Aging: From Awareness to Action: Executive Summary. Washington, DC, Department of Health and Human Services, 20057.2005 White House Conference on Aging: Post-Event Summary Report. Bethesda, Md, Geriatric Mental Health Foundation, 2005. Available at www.gmhfonline.org/gmhf/2005forum.html8.Committee on Aging of the Group for the Advancement of Psychiatry: Medicare managed mental health care: a looming crisis. Psychiatric Services 56:795—797, 20059.Conwell Y: Suicide prevention in later life: a glass half full, or half empty? American Journal of Psychiatry 166:845—848, 200910.Katon WJ, Schoenbaum M, Fan MY, et al: Cost-effectiveness of improving primary care treatment of late-life depression. Archives of General Psychiatry 62:1313—1320, 2005