Training in Geriatric Mental Health: Needs and Strategies

The changing demographics of our society have garnered a great deal of attention in recent years. Based on projections by the U.S. Bureau of the Census (1), the number of persons aged 65 and older will more than double between now and the middle of the next century. This growth can be attributed to the aging of the baby-boom generation—those born between 1946 and 1964—as well as to changes in mortality and morbidity rates. Although some attention has been paid to the projected health care needs of the elderly population, little consideration has been given to mental health needs, including the necessity for appropriate health care professionals.

This paper addresses the need for our society to prepare for the upcoming "age wave" by training the necessary numbers of mental health professionals. Specific strategies for meeting the training needs are suggested.

The current state of affairs

The total number of Americans over age 65, as well as their percentage of the total population, is already greater than it has ever been in history. As of December 1997, Americans over age 65 numbered 34,196,000—12.7 percent of the total population. In 1900 these figures were 3,080,000 and 4.1 percent, in 1940 they were 9,019,000 and 6.8 percent, and in 1990 they were 31,079,000 and 12.5 percent (2). The increase in the number of older adults will continue slowly and steadily between now and 2010, when it will rapidly swell and produce the largest age wave in history.

As a society we have slowly begun to acknowledge this ongoing change in demographics, yet we have done little to prepare for it. The following section briefly discusses how many health care providers are available to treat the mental health needs of the U.S. elderly population and what resources are currently available to continue training.

Currently, there are about 35,000 psychiatrists in the United States. Approximately 5,000 of them list "geriatric or gerontologic psychiatry" as one of their three primary interests (3). The American Association for Geriatric Psychiatry has approximately 1,500 members, and 2,360 psychiatrists nationwide have passed the American Board of Psychiatry and Neurology examination for added qualifications in geriatric psychiatry. A total of 49 accredited geriatric psychiatry fellowship programs exist in the U.S.

Mental health care for the elderly population is also provided by primary care physicians. Their role in this field must not be ignored. However, multiple studies have shown that many of these providers are unprepared to deal with geriatric mental disorders. Most physicians receive little training in mental disorders of elderly persons, and consequently they do not provide optimal treatment to their patients (4,5,6).

About 76,000 psychologists are clinically active in the United States (7). Between 200 (8) and 700 (9) of them would qualify as geropsychologists—that is, they devote half or more of their practice to older adults and their families. The newly organized section for geropsychology in the division of clinical psychology of the American Psychological Association has 238 members. The American Psychological Association's council of representatives has recently approved a proficiency in geropsychology. Approximately 10 percent of accredited psychology programs offer an emphasis on aging for psychology doctoral students, and 30 percent offer an elective course on aging (10,11). An increasing number of clinical internships offer rotations in treating late-life disorders.

The practice skills and knowledge necessary to meet the nursing needs of older patients were specified in the American Nurses' Association (ANA) 1987 standards and scope of gerontological nursing practice. In 1994 the ANA found that approximately 12,500 nurse providers had special training in geriatrics. Only a small proportion of training programs offer coursework in aging. No certification in geropsychiatric nursing is available.

Fewer than 6,000 social workers have any training specific to aging (12). About a third of master's-level social work programs offer courses or a concentration in aging but not necessarily in the mental health aspects of dying. This lack of educational opportunity is largely due to a shortage of faculty who are trained in gerontological social work (12).

Magnitude of the problem

Several factors will play a role in determining the magnitude of the demographic change and the ultimate need to train professionals to work with an aging mentally ill population. These factors include, but are not limited to, the projected health and functional status of the population, the types of health services available, reimbursement strategies, and the ever-increasing scientific knowledge base. Although it does not appear likely that a "cure" for any of the major psychiatric disorders will be discovered by the year 2010, one cannot discount such a possibility and its potential impact on training needs. It is more likely, however, that reimbursement strategies will undergo major changes between now and 2010, which will have a significant impact on training needs.

Projected need for health care professionals

Our society is generally ill prepared to deal with the number of older persons with mental disorders, and this situation will only worsen. It has been estimated that 400 to 500 academic geriatric psychiatrists will be needed by 2010, in addition to 4,000 to 5,000 geriatric psychiatrists who are active in patient care (8). An estimated 1,221 physician faculty members and 919 nonphysician faculty members will be necessary to provide adequate training in geriatric psychiatry over the next ten years (13). These estimates were derived using a model that took into account demographics, training paths, training capacity, and other factors (14).

The American Psychological Association has estimated a need for 5,000 full-time doctoral-level clinical and counseling geropsychologists by 2020 (8). The estimate is based on the assumption that approximately 10 percent of the population aged 65 years and older should receive services from a mental health professional. A similar estimate for the year 2020, based on services to about 28 percent of the elderly population, would exceed 14,000 full-time-equivalent (FTE) personnel.

It has been estimated that by 2000, approximately 595,000 FTE registered nurses, 250,000 licensed practical nurses, and more than 500,000 nursing aides will be needed to care for older patients (15). These figures are in addition to estimates of 19,000 gerontological nurse practitioners and gerontological clinical specialists. A large proportion of these individuals would be required to provide mental health care.

It is also proposed that 50,000 to 60,000 full-time social workers will be needed to serve the needs of our older population around the year 2010 (12). About 5,570 social workers were employed in providing direct service to elderly persons in the early 1980s.

For other general mental health care workers, no studies with estimates could be found. Given the strong societal pressure to contain health care costs, a need for individuals with special training at the baccalaureate or associate-degree level is clear. Also, given the large number of nursing home residents with chronic mental illnesses, including dementia, it is clear that paraprofessionals must also receive appropriate training to meet changing needs.

Again, one must not overlook primary care physicians. A large majority of older people seek mental health care services from their primary care physicians for disorders such as depression and dementia. Research findings have indicated that primary care physicians often fail to adequately detect and treat mental illnesses in older patients. A survey of a group of primary care physicians found that only 66 percent considered themselves "somewhat knowledgeable" about geriatric mental health issues, and another 20 percent considered themselves "not very knowledgeable" (16). Nonetheless, 89 percent of these physicians said that they would be interested in increasing their knowledge of geriatric mental health issues.

The expected state of affairs in 2010

It is anticipated that by 2010, a total of 13.3 percent of the total U.S. population—approximately 40.1 million people—will be over age 65 (1). The prevalence of clinically significant symptoms of depression, anxiety, and other psychiatric disorders in the elderly population is several times higher than the prevalence of corresponding diagnosable disorders (17), and for several reasons the prevalence of both may be even higher by 2010. Evidence suggests differences in rates of mental disorders by cohorts (18), and the prevalence of anxiety disorders and depression among baby boomers may be twice as high as in prior cohorts. Also, greater life expectancy may increase the risk of dementia. The fastest-growing segment of the population includes individuals over age 85. Thus we may experience higher rates of dementia than ever before.

One important trend is the projected increase in the veteran population over age 65. In 1990 a total of 7.1 million Americans over age 65 were veterans (19). Among men age 65 and older, the veteran population was twice as large as the nonveteran population. By 2000 there will be more than 8.9 million elderly veterans, with three times as many veterans as nonveterans among men in this age group. The proportion of individuals over age 65 in the total veteran population will grow phenomenally, from 26 percent in 1990 to 37 percent in 2000 to 40 percent in 2010 (19).

The older population is also becoming increasingly heterogeneous. In the U.S. people from diverse ethnic, cultural, and socioeconomic backgrounds are surviving into old age. For example, the percentage of individuals of Hispanic origin in the elderly U.S. population is expected to increase from 1.1 percent in 1990 to 2.9 percent in 2010 to 12.5 percent in 2050 (1). The black population over age 65 will undergo similar growth, from 2.5 percent in 1990 to 3.4 percent in 2010 to 8.4 percent in 2050 (1).

The "oldest old" will also represent a larger proportion of the population. The population age 85 and older will nearly double from 3 million in 1990 to 5.7 million in 2010 (1). As more people live to the oldest ages, they may live their oldest years with more illnesses and disabilities. Some narrowing of the differences in mortality between men and women may occur, thereby decreasing the proportion of older women to older men.

Strategic planning

Multiple strategies are necessary for ensuring that we are able to provide adequate mental health care to the elderly population. First, some level of core training in the provision of mental health care to older patients must be in place for all disciplines—primary care, psychiatry, psychology, nursing, and social work. Training in assessment and diagnosis should be required in all such programs. This level of training can be provided through basic training programs to new personnel entering the professions and through continuing education for existing professionals. Primary care practitioners, psychiatrists, and psychologists should receive some training in appropriate intervention strategies and referral.

Second, specialty training should be available in each of the professions. Such training can take place through a number of mechanisms, including both didactic and practical training. Specialists will provide services directly to patients and also will take a large degree of responsibility for training other providers. Third, a larger cohort of academic geriatricians must be developed to serve as leaders in research and training.

Implementing the strategies

In relation to implementing the three strategies, we conducted an analysis of strengths, weaknesses, opportunities, and threats.

Strengths

One of the greatest strengths is the increasing recognition of potential problems. As more people become aware of the need for treating older patients, they will advocate for ensuring that providers are appropriately trained. Also, as mental disorders "come out of the closet," seeking treatment from well-trained providers will become less of an issue.

Another strength is the existing cadre of academic geriatricians. Although their number is currently small, this group is generally highly devoted to the field. They have weathered an era of limited support for their endeavors. They have provided care, taught, and conducted research despite limited recognition.

In addition, the leaders of a number of professional organizations have vowed to stand firm behind the training of new clinicians and researchers who will serve the needs of the older population. All of these groups work both separately and together to ensure that new personnel are trained in mental health and aging.

Weaknesses

The number of geriatric and gerontologic specialists in mental health available across the disciplines is exceptionally small given the need. Social stigma and competition for limited resources are among other problems. The supply of both specialists and resources cannot meet current or future demands.

Opportunities

Numerous opportunities exist for improving the current state of affairs given the right environment and adequate resources for change.

The potential political power of the aging population should not be underestimated. Individual citizens and advocacy groups can have a strong impact on the future of mental health care. Organizations such as the American Association of Retired Persons and the National Alliance for the Mentally Ill can deliver a strong message to the nation with the combined support of their members. Legislators respond to large constituent groups. Baby boomers will continue to be an influential constituency.

In keeping with historical trends, American institutions will shift to meet the needs of this cohort. Just as a large number of schools were constructed to meet the educational needs of baby boomers, the health care system will also adapt to the needs of the aging cohort. For example, baby boomers will have the strength to influence the reimbursement strategies employed by the Medicare program, including the role of trainees.

Threats

Long-standing societal biases against mental illness and aging have been and could continue to be a threat to attracting individuals to careers in this field. It will be critical to work to erase these historical biases so that progress can be made toward the goal of increasing the number of individuals trained to meet the mental health needs of an aging population.

Aging and mental illness have both been viewed as chronic "problems." Physicians as well as many other health care providers are trained to "cure" people and, unfortunately, at present neither of these "maladies" can be cured, which connotes failure to the average provider. Central to erasing these biases would be a shift in the whole process of education of health care providers from "cure" to management or optimization of quality of life.

Specific recommendations

Clearly, a need exists to train individuals to meet the needs of the growing population of older adults. Multiple strategies must be implemented to facilitate understanding and training. We present several specific recommendations for addressing these needs.

• Educate the lay public about the common mental disorders of late life. This approach will serve multiple purposes. It will lead people to seek appropriate and effective interventions for treatable disorders, encourage health care providers to become more educated about treating common disorders, and increase the number of advocates for additional research on mental disorders of late life.

• Expand the core curriculum on aging and late-life mental disorders in professional programs. Students should be exposed to an aging-specific curriculum early in their education so that they are aware of geriatric mental health as a potential career path. This approach will ensure that all providers have had some, albeit limited, education in the field.

• Increase incentives for individuals who seek specialty training in geriatric mental health. These incentives might include loan forgiveness and increased reimbursement for specialty services. The Department of Veterans Affairs and the National Institutes of Health can be particularly aggressive in this area.

• Diversify the range of advanced training opportunities available, including programs for those with clinical interest only or research interest only and those with both clinical and research interests.

• Encourage professional organizations to offer certification in disciplines related to aging to highlight the increased knowledge of specialists within their field. Individuals with certification can serve as consultants and educators.

• Increase midcareer training opportunities. This strategy is likely to have one of the largest impacts. Opportunities ranging from continuing education to in-depth experiences such as fellowships should be offered. Incentives, particularly for more intensive training, should be provided. Both the private sector, such as the pharmaceutical industry, medical device companies, and managed care, and the public sector, including health care agencies and research agencies, have a strong potential financial incentive to provide adequate training in geriatric mental health.

• Establish short-term, creative training initiatives to meet specific demands. A model for this approach might be the week-long summer research institute in geriatric psychiatry described by Halpain and associates (20). The institute is an annual intensive research training experience intended to prepare junior scientists for careers in academic geriatric mental health.

• Increase federal, state, and private research funding for late-life mental disorders, especially in developing and testing new interventions. This strategy also will serve multiple purposes. It will lead people to seek research careers in late-life mental disorders, increase the base of academic faculty available to provide training in geriatric mental health, and increase scientific findings that may lead to new interventions or prevention of late-life mental disorders.

• Establish "centers of excellence" to provide multidisciplinary training environments.

• Increase information technology so that research results can be translated quickly to clinical practice. Appropriate diagnosis and treatment of diseases depend on having an adequate and competent pool of health care providers. No step to improve training will be too small.

Acknowledgments

This work was partly supported by grants MH-19934, MH-19934, MH-19946, MH-49671, MH-45131, and MH-43693 from the National Institute of Mental Health; by grant A3E-1-10 from the state of California academic geriatric resource program; and by the Department of Veterans Affairs.

The authors are affiliated with the Geriatric Psychiatry Intervention Research Center of the department of psychiatry at the University of California, San Diego, and the Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, California 92161 (e-mail, [email protected]). Ms. Halpain is manager, Dr. Harris is codirector, Dr. McClure is a postdoctoral fellow, and Dr. Jeste is director. Dr. Jeste is also professor of psychiatry and neurosciences in the department. This paper is part of a special section on meeting the mental health needs of the growing population of elderly persons.