Roadblock Ahead

Along with spring flowers and rising temperatures, April heralds the beginning of the construction season in northern latitudes. Motorists on their commute to work frequently see orange barrels indicating road blocks or lane narrowing and must plan accordingly to be on time for essential appointments and meetings. Similarly, the signs are clear that there is trouble on the road to providing psychiatric services to the rapidly increasing population in U.S. nursing homes and senior facilities. The number of Americans aged 65 or older will grow from 35 million in 2000 to an estimated 71 million in 2030, and the population aged 80 or older will increase from 9.3 million to 19.5 million.

In this month's issue two articles—one by Yue Li, Ph.D., and another by Sonne P. Lemke, Ph.D., and Jeanne A. Schaefer, Ph.D., R.N.—separately address the increasingly critical issue of nursing home residents with mental disorders and raise questions and concerns about how best to meet future needs. The Omnibus Budget Reconciliation Act (OBRA) of 1987 required that individuals who are appropriately placed and residing in nursing homes receive adequate mental health services. As Dr. Li points out, approximately 17,000 U.S. nursing homes provide care to more than 1.6 million individuals annually, and in the post-OBRA years, mental health services have not been adequately provided in about one in five U.S. nursing homes. There are a number of apparent explanations, including insufficient access to care, lack of clinical expertise, and poor financial and infrastructure supports. Because of the significant psychiatric and medical comorbidity in this population, it has been suggested that the ideal method of delivering mental health services in nursing homes is the inclusion of a mental health specialist on the multidisciplinary team. However, availability of psychiatric consultants is limited in many locations, and geropsychiatric services are especially scarce. Inadequate coverage of mental health services by Medicare and Medicaid, which account for a majority of nursing home payments, does not provide much incentive for mental health specialists to offer services in these settings. In recent years the Food and Drug Administration has mandated warnings about the use of some pharmacologic therapies—notably antipsychotic drugs—in populations with dementia, and nonpharmacologic or behavioral interventions for nursing home residents with mental disorders are generally not reimbursed or poorly reimbursed.

What is clear from national demographic trends and emerging research is that the current infrastructure is unable to keep up with the mental health needs of elders in nursing homes, and this problem will be compounded over the next two decades. There is a major problem down the road if policy makers, insurers, and health care professionals do not collaborate to develop and expand essential mental health services in nursing homes.