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Mental Health and Aging

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Authored by Kate Krajci, MA, LCSW; Matthew Vail, MA, LCSW; and Robyn Golden, MA, LCSW

Introduction

Mental health is a key element of overall health and well-being in older adulthood. Individuals with mental health needs face significant impacts on daily functioning, socialization, meaningful relationships, and health and safety. While not a normal part of aging, in 2017 roughly 20% of adults over 60 suffered from a mental health or neurological disorder. In fact, this estimate may be low, as research consistently documents the challenges of obtaining accurate measures of mental health in older adults due to underdiagnosis, varied definitions of the terms "mental health" and "older adult,"  and different sampling methods for individuals living in the community compared to those who are homeless or living in nursing home settings.

Given the growing number of older adults and service systems unprepared to meet their mental health needs, there are many opportunities for grantmakers to support programs and efforts that will enhance lives and improve access to quality care.

What is unique about mental health in older adults?

In older adulthood a variety of losses (for example, changes in roles, living arrangements, ability to perform certain activities, deaths of loved ones), chronic illnesses, cognitive, functional and sensory impairments as well as physiological changes of normal aging directly influence the risk of developing a mental health condition as well as the course of that condition. While these circumstances can occur at any time during a person's life, they are more likely both to occur and to be a consistent presence in the life of an older adult. If the older adult is not able to cope effectively with the cumulative effects of these stressors, mental health concerns may be triggered or perpetuated. 

In addition, the complex interaction between age-related circumstances and mental health symptoms frequently complicates accurate identification, diagnosis, and treatment in older adulthood. The impacts of these circumstances often mimic formal mental health diagnoses that need treatment and vice versa. For example, in an older adult with multiple losses, it may be difficult to determine if his or her reactions are normative grief or depression. Memory problems may be depression, early signs of dementia, or complications from medical conditions or medication side effects. Isolation and withdrawal from usual activities may be due to depression, dementia, physical impairments, or hearing loss.

Certain health conditions—for example, cardiac disease, Parkinson's disease, and diabetes—often correlate with depression. Or perhaps due to physiological changes in how medications are metabolized, medication interactions may trigger symptoms that look like depression. Identifying depression can be particularly difficult, as depressed older adults are less likely to exhibit low mood and more likely to exhibit anhedonia compared to other age cohorts. These confusing overlays, especially when coupled with ageist stereotypes, complicate assessment and care planning. In fact, studies show that 40-90% of older adult mental health concerns are not detected in primary care, the setting where the majority of individuals, regardless of age, obtain mental health treatment.

This represents a significant missed opportunity. A 2015 study showed that a majority of older adults who were screened for depression in primary care found it easy to talk to their doctors about depression and anxiety, and that they did not find the conversation embarrassing or uncomfortable. Therefore routine mental health screening in traditional health care settings is essential. In 2016, the US Preventive Services Task Force concluded that adults who are diagnosed with depression via primary care screening and provided with psychotherapy, antidepressants, or both, had decreased clinical morbidity.

Lifetime exposure to, and experiences with, mental health issues are also unique in older adults. Individuals may be experiencing mental health needs for the first time or may be entering older adulthood with a life-long history of symptoms. Older adults with a history of mental health needs will carry the physical and psychosocial impacts of their condition as well as their experiences (or lack thereof) with various treatments and service systems. Cohort issues are also at play. The current cohort of older adults lived during various eras of mental health perception and treatment in America. Their experiences range from significant mental health stigma and treatments that often correlated with negative side effects or institutionalization to more open acknowledgement of mental health needs, active use of various substances, and psychotherapy as a normative experience. This cohort effect impacts how older adults self-identify, experience, and describe their emotions; many of the "middle old" and "oldest old" older adults express emotional distress through physical symptoms or vague complaints that are not properly identified by professionals as mental health issues. Across the current and increasingly diverse population of older adults, cohort effects also impact outreach, education, assessment, and engagement strategies as well as treatment expectations..

While not the majority of older adults, those who experience mental health issues face serious consequences in multiple domains of life. Research shows that older adults with mental health issues experience consistent negative impacts, including emotional distress, strained social relationships and isolation, and decreased quality of life. They also experience increased complexity and number of medical conditions, disability and impairment, outpatient, emergency department and inpatient health care utilization, caregiver stress, mortality, and risk of suicide. Therefore identification and treatment of mental health issues stands to improve older adults’ lives in many ways..

In addition to these direct negative consequences for the older adult, mental health and aging also has implications for the healthcare system. For example, compared to older adults without depression, those with depression had nearly twice the number of outpatient visits and when hospitalized, had twice the number of inpatient days over the anticipated discharge date. Individuals with symptoms of depression also represented 75% of patients who overutilize primary care services. Older adults with mental health disorders account for over 25% of mental health-related emergency department visits. These numbers will continue to increase as the “boomer” population ages. In the current healthcare environment focused on improving quality, improving population health, and decreasing cost, investment in improved identification and treatment of older adults' mental health issues can have impact on both individual and systemic levels.

Defining mental health

Older adults face a variety of mental health concerns, including depression, anxiety, substance use, trauma, serious mental illness, and personality disorders. Hoarding is also a significant concern garnering increasing attention. When considering the mental health needs of older adults, it is important to acknowledge that mental health conditions often occur with each other. The Institute of Medicine's comprehensive 2012 review estimates that 6.8-10.2% of people 65 years or older have one or more mental health conditions, with 2.0-2.4% having two or more and 0.5-0.8% with three or more. A 2015 study of over 12,000 older Americans found that the proportion who experienced an anxiety disorder was 11.4%, while the prevalence of any mood disorder was 6.8%. A total of 3.8% of older adults met criteria for any past-year substance use disorder, and 14.5% of older adults had one or more personality disorder. It is notable that when the researchers stratified the sample by age, they discovered decreasing rates of mental health disorders with increasing age. This leveling off effect can be explained by the fact that the oldest cohort of adults in the study adopted a present-focused state of awareness, sought the fulfillment of emotionally meaningful goals, and spent time with familiar social partners.

To be formally diagnosed with a mental health condition, an individual must experience a constellation of symptoms that impact day-to-day functioning over discreet periods of time. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) details conditions and diagnostic criteria. A brief overview will enhance grantmakers' understanding of common conditions impacting older adults.

Treatment

Literature suggests that older adults hold contradictory views on mental health treatment. Though 80-90% are open to seeking help for mental health concerns and believe treatment will help, roughly a  quarter to a third of older adults believe these conditions are best handled alone or will go away with time. Many older adults with mental health conditions do not perceive that they need treatment or actively choose not to pursue it. In addition, research consistently finds that compared to younger adults, older adults with mental health needs are less likely to obtain treatment in general, but especially from mental health specialty programs. Factors influencing this underutilization include stigma, not knowing where to go for help, concerns about cost, and professionals not identifying mental health concerns. When treatment is obtained, it tends to be via medication through a primary care physician or services from community-based agencies.    

Despite these utilization trends, it is estimated that in 2009, services and medications for mental health disorders in Americans age 65 and older cost $17.1 billion, setting mental health within the top ten most costly conditions for this age group. Just over half (52.5%) of the costs were paid by Medicare, with out-of-pocket (18.3%), private insurance (11.7%), Medicaid (11.4%), and other sources (6.1%) covering the balance. Various federal policy changes in recent years have improved Medicare and other insurance coverage of mental health screenings and treatment. However, limitations still exist and simultaneous cuts in state and local budgets have caused many providers to reduce or eliminate services. This formal reimbursement landscape results in many gaps that grantmakers can fill at both program and advocacy levels.

As with younger populations, the majority of mental health concerns can be effectively treated in older adults. A combination of prescription medication and psychotherapy (also known as talk therapy) remains ideal treatment, but the use of medication has increased over time while psychotherapy has decreased. Regardless, a substantial evidence base shows the effectiveness of psychotherapy with older adults. Individual psychotherapy typically is billed to insurance or, with less frequency, paid entirely out-of-pocket. Like outpatient medical care, Medicare covers 80% of its agreed-to fee for contracted psychologists and licensed clinical social workers. Telephonic treatment is not covered and as discussed, an individual must meet diagnostic criteria for a mental health condition. Medicaid coverage varies by state, treatment setting, and provider type. 

Individual psychotherapy is offered in a variety of settings ranging from private practices to community-based services to professionals integrated in primary care. Psychotherapy is also offered as part of broader, structured programs that can be implemented by a variety of professionals in community-based or medical settings. These programs typically have mixed funding sources, including grant funding.  The following are well-researched evidence-based programs that include psychotherapy:

  • Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) is a primary care, team-based program that includes psychotherapy and rigorous symptom monitoring via a care manager for older adults with depression. It is a long-term intervention, lasting several months or over one year. IMPACT has received extensive support from The John A. Hartford Foundation (NY).\
  • Program to Encourage Active and Rewarding Lives (PEARLS, formerly Program for Encouraging Active Rewarding Lives for Seniors) is an in-home, team-based program that includes psychotherapy for physically-impaired, isolated older adults with varying degrees of depression. It is designed to integrate into typical community-based case management activities and last roughly six months.

As discussed, identification of mental health conditions and consumer education are also significant areas of need. While Medicare now covers depression and substance use screenings in primary care, screenings in other settings or for other mental health conditions typically cannot be reimbursed by insurance. Consumer education and outreach are largely unfunded areas and many programs turn to grants to support or supplement limited funds from federal and state sources. The following evidence-based programs focus on screening and identification, with behavioral activities that can improve symptoms without formalized psychotherapy or motivate the older adult to pursue formalized treatment:

  • Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) integrates depression screening, education, simple behavioral change activities, and coordination across service systems into long-term community-based care management services for chronically ill older adults. Services are provided both in-home as well as by telephone over the course of three to six months. Professionals offering the intervention do not need to have formalized mental health training, though such prior experience is helpful.
  • Screening Brief Intervention and Referral to Treatment (SBIRT) is a method for substance use screening, education to prevent problem use and abuse, and connection to formalized treatment for individuals using at abuse or dependence levels. Because it is not formal treatment, the method is highly flexible and can be offered in all service settings by any level of professional, though those with mental health training will more quickly be able to implement the method. While models vary, SBIRT interventions can be as short as a one-time, 15-45 minute session. An SBIRT model created specifically for older adults is available and was utilized in the Brief Intervention and Treatment for Elders (BRITE) program.

The majority of older adults obtain mental health treatment via medical primary care practices. Though dated, research has found that among older adults, 50-75% of all primary care visits focus on a mental health issue, yet these concerns also often go undetected in this setting. There are numerous past and present efforts to increase the integration of older adult mental health screenings and access to treatment via primary care, especially in light of the Affordable Care Act. Now more than ever, it is critical to bolster primary care professionals' ability to screen, diagnose, and connect patients with appropriate mental health treatment. This will also require increased capacity of primary care to collaborate with community-based providers in the mental health, substance use, and aging systems.

Three of the most widely known primary care-based programs with evidence as to their effectiveness are IMPACTPrevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT); and the Collaborative Care model developed by the AIMS Center at University of Washington. 

Like IMPACT, PROSPECT also utilizes depression care managers as part of team-based primary care and includes both medication and psychotherapy interventions. Lasting 24 months, it is a lengthy intervention and has not been replicated or disseminated as widely as IMPACT. The Collaborative Care model integrates mental health care managers and consulting psychiatrists into primary care teams to offer face-to-face mental health services. There is significant potential to develop and research additional models of primary care based programs for mental health in older adults given the length of current interventions and their exclusive focus on depression.

Clearly there is a strong evidence base for a variety of screening and treatment programs for the mental health needs of older adults, particularly regarding depression. Unfortunately, research consistently shows a limited number of specially trained providers to execute them. While providers with a variety of education levels offer mental health treatment, many are not familiar with aging issues. Similarly, many professionals in the field of aging are not familiar enough with mental health issues, especially substance use.

When one considers the intersection of mental health and aging, the typical specialty providers are psychiatrists, psychologists, and social workers. As of 2010, there were only 1,382 board-certified geriatric psychiatrists in the United States. In 2008, 4.2% of licensed psychologists surveyed by the American Psychological Association indicated geropsychology as their focus. And a 2006 study showed that only 9% of social workers report aging as their primary area of focus, despite the fact that nearly 78% indicate they work with older adults.

Because of less-than-ideal reimbursement rates, many mental health providers do not accept Medicare, adding to the shortage of available professionals and disincentivizing professionals to pursue mental health and aging. In addition, specialty training programs and certifications across all disciplines are limited or underutilized. There are also seems to be widespread stigma among students entering a mental health field when it comes to working with older adults. A survey of high school students interested in nursing found that 48 percent had no interest in specializing in geriatrics. A survey that asked MSW students from three large universities about their preferred client populations showed that the least popular choice was older adults. Awareness raising, training and advocacy for improved reimbursements and tuition/loan programs are needed for both students and practicing professionals to build the workforce necessary to meet current and future demands for competent care. 

Role of Philanthropy

The John A. Hartford Foundation in New York City has been very active in supporting mental health and aging initiatives over the years. In particular, it has supported training for geropsychiatric nurses and social workers, and funded Centers of Excellence in Geriatric Psychiatry. It also supported the IMPACT program described above, which aims to enhance the care of older people with depression.

Michigan Health Endowment Fund focuses on the health of children and seniors and reducing health care costs. In 2018, the Fund awarded $441,686 to Wayne State University. Wayne State will partner with a federal qualified health center to integrate care for older adults with behavioral health problems in the home using a team-based telemedicine approach.

Archstone Foundation supports innovative responses to the emerging and unmet needs of older adults and is seeking to improve quality of life for adults 65 and older through its Depression in Late Life Initiative. Through a partnership with the University of Washington and the University of California, Davis, the Archstone Foundation will fund initiatives for collaborative care for depression through its Care Partners: Bridging Families, Clinics, and Communities to Advance Late-Life Depression Care project.

Lovell Foundation includes mental health as one of its four funding priority areas and awarded $3.7 million in 2017, including 5 in areas of mental health. In 2018, the Foundation awarded another $2.1 million, that included three in mental health.

The Harry and Jeanette Weinberg Foundation, one of the largest private charitable foundations in the United States, is dedicated to meeting the basic needs of vulnerable people and families experiencing poverty. In 2019, the Foundation will provide approximately $125 million in grants to nonprofits, primarily in the US and Israel, that provide direct services in the areas of Housing, Health, Jobs, Education, and Community Services. Grants focus on supporting organizations that serve specific populations, including older adults, women and children at risk, people with disabilities, and veterans, as well as the Jewish community.

Trending topics

Any investment in older adult mental health stands to have meaningful impact on the lives of older adults and how professionals understand mental health needs, trends, and service provision. Three issues discussed above—substance abuse, trauma, and development of a trained workforce in mental health and aging—are prime areas where grantmakers can make a substantial contribution. Other issues that are emerging as significant in the field of mental health and older adults are:

​Source: Rush University Medical Center November 2014

Resources

Databases and Resources 

  • National Council on Aging (NCOA) Center for Healthy Aging, Behavioral Health Tools and Resources: Offers links to webinars, fact sheets, issue briefs and other helpful tools grantmakers and providers can use to better understand key issues in mental health and aging as well as evidence-based programs, funding issues, and sustainability lessons from previous programs.
  • Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-based Programs and Practices: A searchable database of mental health and substance abuse interventions. The advanced search tool allows "older adult" as a search requirement.
  • GeroCentral: Intended for psychology providers to access information regarding mental health and aging, the site offers excellent brief overviews of mental health conditions, treatments, and treatment settings, many written by leading clinicians. Policy, advocacy, research, professional training, and funding issues are also reviewed. While content is targeted to psychologists, information is applicable to any professional or grantmaker. A collaboration of the American Psychological Association, the Council of Professional Geropsychology Training Programs, and Psychologists in Long Term Care.
  • “Silver and Blue: The Unfinished Business of Mental Health Care for Older Adults,” a national poll conducted by The John A. Hartford Foundaiton. The poll's findings found that a large number of older Americans with depression, anxiety, or other mental health disorders are receiving treatment that does not meet evidence-based standards, and many do not know that depression can put their health at increased risk. A complete list of findings, including care preferences, shortcomings in care, reasons for stopping treatment, stigma, and misconceptions are available.

Issue Briefs and Reports

National Council on Aging Center for Healthy Aging, Behavioral Health Tools and Resources Issue Briefs (2012): A one-stop, online location for a series of 13 issue briefs focusing on clinical, program, policy, and funding issues in mental health and aging.

Institute of Medicine, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (2012): "Report at a Glance" section contains summary documents focused on workforce issues but also offers basic information about mental health and aging. "Get this Report" section allows free download or hard-copy purchase of an excellent, in-depth exploration of many topics related to mental health and aging in addition to workforce needs and development. Comprehensively researched, a must-read for individuals seeking detailed information about mental health and aging.

Mental Health of Older Adults (2017) from the World Health Organization (WHO) details the mental health-related issues facing older adults, as well as WHO’s planned response and recommendations.

Older Americans Behavioral Health: Issue Brief  (2012). The Substance Abuse and Mental Health Services Administration (SAMHSA) and Administration on Aging (AoA) partnered to develop this series of Issue Briefs to address behavioral health issues that are important to older Americans.

Mental Health Services for Older Adults: Creating a System That Tells the Story (2018). A health policy brief from the UCLA Center for Health Policy Research.

National Organizations Focusing on Mental Health and Aging

Administration for Community Living

American Society on Aging's Mental Health and Aging Network constituent group

The Center for Health and Social Care Integration

Geriatric Mental Health Foundation

National Alliance on Mental Illness

National Center for Post-Traumatic Stress Disorder

National Coalition on Mental Health and Aging

National Institute of Mental Health

Substance Abuse and Mental Health Services Administration
In particular, click on Publications and use Advanced Search tool to enter "Older adults” as population for practitioner guides, research summary reports, and consumer education pamphlets regarding mental health, substance use, and aging.

Updated February 2019

 

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