Hearing on the Report of The President's New Freedom Commission on Mental Health (Statement)
Subcommittee on Substance Abuse and Mental Health Services, Committee on Health, Education, Labor, and Pensions, U.S. Senate
American Association for Geriatric Psychiatry
11/4/2003
Statement for the Record
The American Association for Geriatric Psychiatry (AAGP) is pleased to have the opportunity to submit a statement for the record on the report of the President’s New Freedom Commission on Mental Health. AAGP is a professional membership organization dedicated to promoting the mental health and well-being of older people and improving the care of those with late-life mental disorders. AAGP’s membership consists of approximately 2,000 geriatric psychiatrists, as well as other health professionals who focus on the mental health problems faced by senior citizens.
The Commission, after beginning its work without explicit plans to address issues of particular concern to older adults, heard the concerns of consumers and practitioners about the need to address these issues separately and subsequently established a subcommittee on older adults.
AAGP was pleased to note that the Commission’s interim report to the President identified the gap in treatment to older adults with mental illnesses as one of the five major barriers to care within the mental health system. With respect to older adults, the interim report noted the growing numbers of persons with unrecognized and untreated depression, their high rates of suicide, and the implications for the future as the baby boom generation ages.
The AAGP commends the Commission for bringing to light, in its final report, many of the problems of access to quality mental health care. But, given the concern about treatment for older adults expressed in the interim report, AAGP was surprised and disturbed to learn that, in its final report, the Commission was almost silent on the mental health problems and needs of seniors and had no recommendations specifically targeted for the senior population.
With the aging of the U.S. population, there will be an unprecedented increase in burden of mental illness among older persons. By the year 2010, there will be 40 million people in the United States over the age of 65. Over 20 percent will experience mental health problems, problems that are not an inevitable part of aging. As a result, research holds the immense promise of improving the mental health and independence for older Americans.
Depression is a common problem among older persons. Of the 32 million Americans aged 65 and older, five million suffer from depression, resulting in unnecessary disability, excess health care utilization, avoidable family burden, and premature mortality. Depression, anxiety, dementia, and substance abuse are often misdiagnosed or not recognized by primary and specialty care physicians. Depression often co-occurs with chronic conditions such as heart disease, cancer, stroke, and diabetes. Research has shown that treatment of mental illness in the context of chronic physical disease improves survival and well-being.
The 1999 Surgeon General’s Report on Mental Health and the 2001 Administration on Aging Report on Older Adults and Mental Health underscore both the prevalence of mental disorders in older persons and the evidence that research is developing effective treatments. Scientifically tested treatments are effective in relieving symptoms, improving function, and enhancing quality of life. These interventions reduce the need for costly hospitalizations and long-term care without simply shifting the burden to the family. However, there is a pronounced gap between the emergence of effective treatment and subsequent implementation by health care providers. This gap can be as long as 15 years. If we delay new treatments to the present
4 million Americans with dementia the way we delayed the treatment of depression, a generation of seniors will have been needlessly admitted to nursing homes. The Surgeon General and Administration on Aging reports stress the need for translational and health services research to identify the most cost-effective interventions, as well as effective methods of care delivery.
Special attention needs to be paid to investigations of serious but neglected late-life mental disorders. Schizophrenia, anxiety disorders, alcohol dependence and personality disorders have been largely ignored by both the research community and the funding agencies, despite the fact that these conditions take a major toll on patients and their families. AAGP’s members are at the forefront of research on Alzheimer’s disease, depression, and psychosis among the elderly, and we believe that more science must be focused in these areas. Improving the treatment of late-life mental health problems will benefit not only the elderly, but also their children, whose lives are often profoundly affected. Caregiving itself is an enormous drain on the financial security and health of family members, too many of whom become depressed as a result.
There are also problems with access to care. Dissemination of science-based practices in “real world” settings must be a top priority. Despite significant advances in research on the causes and treatment of mental disorders, there is a major gap between these research findings and clinical practice. The greatest challenge for the future of mental health care is to bridge this gap.
Effective treatment for mental illnesses in late life is theoretically available, but access to health professionals trained in geriatric care is not. The number of health care practitioners with training in geriatrics is wholly inadequate. As the population ages, the absolute number of older Americans experiencing mental problems will certainly increase even if the rates of the disorders do not. Since geriatric specialists are already in short supply, these demographic trends will only make them more so. There must be substantially more public and private investment in geriatric education and training. We will never have, nor will we need, a geriatric specialist for every older adult. However, without mainstreaming geriatrics into every aspect of medical education and physician training, broad-based geriatric competence in health care will never be achieved. We need incentives to increase the number of geriatric educators not only in medicine but also in the disciplines of social work, psychology, nursing, and substance abuse.
Lack of training is aggravated by lack of reimbursement for treatment. Under current law, Medicare requires beneficiaries to pay a 20 percent copayment for Part B services with the single exception of a requirement of a 50 percent copayment for outpatient mental health services. The lack of parity for mental health treatment is unconscionable – and of great consequence to older adults who feel more stigmatized by psychiatric illness than any other group. Despite widespread need, many seniors decline, delay, or drop out of treatment because of the high copayment. In addition, current law discriminates against the non-elderly disabled Medicare population, many of whom have severe mental disorders.
Even if all access problems were resolved, it would be difficult for the most knowledgeable of geriatric psychiatrists to prescribe optimally for their elderly patients. The FDA requires the pharmaceutical industry to test the safety and efficacy of medicines in children. A similar rule is needed to protect older adults. FDA approval for most new drugs is based on research in younger adults. These studies typically exclude children, the aged, and those who have more than one health problem or who take multiple medications. That is the very profile of many seniors who seek treatment.
In conclusion, it is imperative that SAMSHA and other Federal agencies charged with implementing this report, address the distinct mental health issues facing our nation’s seniors. The sheer numbers of older Americans – treated by practitioners who have inadequate training, suffering from physical disease exacerbated by mental illness, taking medications that are prescribed based on inadequate science – demand attention. We owe this much to our seniors now, just as we owe it to ourselves in the future.
AAGP appreciates having the opportunity to present this statement for the Subcommittee’s consideration.
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