INTRODUCTION
Of the estimated 40 million Americans who will be 65 or older by 2010, more than 20 percent will experience some type of mental health problem, the American Association for Geriatric Psychiatry estimates. Depression is particularly prevalent. Anywhere from 8 percent to 20 percent of the elderly experience symptoms of the disorder, which may help to explain why older Americans have the highest suicide rate of any age group. For white men age 85 and older, for example, the suicide death rate in 1999 was 59 per 100,000, more than five times the national rate of 10.7 per 100,000.
Despite the breadth of the problem, however, a number of studies suggest that older adults underutilize mental health services, for a variety of reasons. Besides the stigma that still surrounds mental illness and its treatment, barriers include a fragmented service delivery system, a dearth of appropriately trained providers and a lack of funds to pay for the services.
Even in nursing homes, where teams of medical professionals monitor the health conditions of residents, mental health problems go largely undiagnosed and untreated. According to the American Psychological Association, for example, two-thirds of elderly nursing home residents exhibit mental and behavioral problems but less than 3 percent report seeing a mental health professional.
Source: Coffey, R. et al. National Estimates of Expenditures for Mental Health and Substance Abuse Treatment, 1997. Office of Organization and Financing, Substance Abuse and Mental Health Services Administration. (SAMHSA. Rockville, MD: July 2000).
Older persons with serious mental health problems who require treatment fall into two distinct groups: people with a long-standing chronic mental illness and people with late-onset illnesses, typically depression or anxiety disorders. Because many of those in the first group have been disabled during their adult working years, they are more likely to qualify for Medicaid and thus are more likely to receive services than those with late-onset mental illness. Those in the second group-significantly larger in number-are less likely to receive treatment for their disorder, unless they have been formally admitted to a private or public psychiatric hospital.
Funds for mental health treatment derive from an array of sources: state and local governments, Medicaid and private insurance. In addition, states receive federal money under Mental Health Services Block Grant. (Please see chart this page for breakdown of public spending.) Medicare, which picks up the bulk of the tab for health services for the 65-and-over population, reimburses for some mental health services, but coverage is very limited-outpatient prescription drugs are excluded, for instance-and requires substantial cost sharing for many of the services that are covered. Medicare only covers 50 percent of outpatient mental health services.
Because Medicare fees are based on the amount of time involved in rendering a given service to a typical adult patient, not a geriatric patient, many mental health providers are reluctant to accept older, mentally ill patients. And because seniors with a mental illness often have chronic mental health problems, moreover, they require more coordination of care with other health professionals and family caregivers. Again, Medicare does not pay for care coordination.
Another barrier to treatment is a shortage of trained providers-not just those who specialize in geriatric mental and behavioral health care but those who provide primary health care services to older adults as well. Training opportunities for those entering and currently working in the field must include multidisciplinary cross-training, experts say, if treatment of the problem is to improve.
In an effort to shed light on the problem, the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the U.S. Department of Health and Human Services developed a strategic plan in 2001, titled "Substance Abuse and Mental Health Issues Facing Older Adults 2001-2006." The plan lists eight goals to improve the quality of service for older adults. They are: 1) develop a higher level of core competence in working with older adults; 2) instill greater sensitivity among providers, caregivers and the public on issues of diversity and the aging process; 3) improve access to appropriate services; 4) improve screening, assessment and diagnosis; 5) achieve broad dissemination of evidence-based practices; 6) foster a full knowledge, development and application (KDA) cycle for aging initiatives within SAMHSA; 7) devise new approaches to financing substance abuse, mental health and aging services, and 8) develop policy through strong agency coordination.
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