Testimony

FY 2005 Appropriations for Mental Health Research and Services

Subcommittee on Labor, Health and Human Services and Education, House of Representatives Committee on Appropriations

American Association for Geriatric Psychiatry

• demographic projections inform us that, with the aging of the U.S. population, there will be an unprecedented increase in the burden of mental illness among aging persons, especially among the baby boom generation;
  
• this growth in the proportion of older adults and the prevalence of mental illness is expected to have a major direct and indirect impact on general health service use and costs;
  
• despite the fact that effective treatment exists, the current mental health needs of many older adults remain unmet;
  
• the number of physicians being trained in geriatric mental health research and clinical care is insufficient to meet current needs, and this workforce shortfall is projected to become a crisis as the U.S. population ages over the next decade;
  
• a major gap exists between research, mental health care policy, and service delivery; and
  
• despite recent significant increases in appropriations for support of research in mental health, the allocation of NIMH and CMHS funds for research that focuses specifically on aging and mental health is disproportionately low, and woefully inadequate to deal with the impending crisis of mental health in older Americans.
  
  Demographic Projections and the Mental Disorders of Aging
  With the baby boom generation nearing retirement, the number of older Americans with mental disorders is certain to increase in the future. By the year 2010, there will be approximately 40 million people in the United States over the age of 65. Over 20 percent of those people will experience mental health problems. A national crisis in geriatric mental health care is emerging and has received recent attention in the medical literature. Action must be taken now to avert serious problems in the near future. While many different types of mental and behavioral disorders can occur late in life, they are not an inevitable part of the aging process, and continued research holds the promise of improving the mental health and quality of life for older Americans.
  
  The current number of health care practitioners, including physicians, who have training in geriatrics is inadequate. As the population ages, the number of older Americans experiencing mental problems will almost certainly increase. Since geriatric specialists are already in short supply, these demographic trends portend an intensifying shortage in the future. There must be a substantial public and private sector investment in geriatric education and training, with attention given to the importance of geriatric mental health needs. We will never have, nor will we need, a geriatric specialist for every older adult. However, without mainstreaming geriatrics into every aspect of medical school education and residency training, broad-based competence in geriatrics will never be achieved. There must be adequate funding to provide incentives to increase the number of academic geriatricians to train health professionals from a variety of disciplines, including geriatric medicine and geriatric psychiatry.
  
  Current and projected economic costs of mental disorders alone are staggering. The direct medical expense to care for a patient with Alzheimer’s disease ranges from $18,000 to $36,000 a year per patient, depending on the severity of the disease. In addition, there are substantial indirect costs associated with caring for an Alzheimer’s disease patient including social support, care giving, and often nursing home care. It is estimated that total costs associated with the care of patients with Alzheimer’s disease is over $100 billion per year in the United States. Psychiatric symptoms (including depression, agitation, and psychotic symptoms) affect 30 to 40 percent of people with Alzheimer’s and are associated with increased hospitalization, nursing home placement, and family burden. These psychiatric symptoms, associated with Alzheimer’s disease, can increase the cost of treating these patients by more than 20 percent. Although NIA has supported extensive research on the cause and treatment of Alzheimer’s, treatment of these behavioral and psychiatric symptoms has been neglected and should be supported through NIMH.
  
  Depression is another example of a common problem among older persons. Approximately 30 percent of older persons in primary care settings have significant symptoms of depression; and depression is associated with greater health care costs, poorer health outcomes, and increased mortality. Of the approximately 32 million Americans who have attained age 65, about five million suffer from depression, resulting in increased disability, general health care utilization, and increased risk of suicide. Older adults have the highest rate of suicide rate compared to any other age group. Comprising only 13 percent of the U.S. population, individuals age 65 and older account for 19 percent of all suicides. The suicide rate for those 85 and older is twice the national average. More than half of older persons who commit suicide visited their primary care physician in the prior month – a truly stunning statistic.
  
  The enormous and widely underestimated costs of late-life mental disorders justify major new investments. The personal and societal costs of mental illness and addictive disorders are high, but advances in research and treatment will help save lives, strengthen families, and save taxpayer dollars.
  
  The Benefits of Research on Public Health
  The U.S. Surgeon General’s Report on Mental Health (1999) and the Administration on Aging Report on Older Adults and Mental Health (2001) underscore the prevalence of mental disorders in older persons and provide evidence that research has lead to the development of effective treatments. These reports summarize research findings showing that treatments are effective in relieving symptoms, improving functioning, and enhancing quality of life. Preliminary findings suggest that these interventions reduce the need for expensive and intensive acute and long-term services. However, it is also well demonstrated that there is a pronounced gap between research findings on the most effective treatment interventions and implementation by health care providers. This gap can be as long as 15 to 20 years. These reports stress the need for translational and health services research focused on identifying the most cost-effective interventions, as well as creating effective methods for improving the quality of health care practice in usual care settings. A major priority (neglected to date) is the development of a health services research agenda that examines the effectiveness and costs of proven models of mental health service delivery for older persons.
  
  Special attention also needs to be paid to inadequately or poorly studied, serious late-life mental disorders. Illnesses such as 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, their care givers, and society at large. Many of AAGP’s members are at the forefront of groundbreaking research on Alzheimer’s disease, depression, and psychosis among the elderly, and we strongly believe that more research funds 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 by their parents’ illness.
  
  While the funding increases supported by this Subcommittee in recent years have been essential first steps to a better future, a committed and sustained investment in research is necessary to allow continuous progress on the many research advances made to date.
  
  National Institute of Mental Health
  In his FY 2005 budget, the President proposed an increase of $729 million for the National Institutes of Health (NIH), which would bring the entire NIH budget to a level of $28.8 billion. However, this 2.6 percent increase over the FY 2004 funding level pales in comparison with recent annual double-digit increases. A decline in adequate funding increases could have a devastating impact on the ability of NIH to sustain the ongoing, multi-year research grants that have been initiated in recent years.
  
  For NIMH, the President is proposing $1.421 billion for scientific and clinical research, a 2.8 percent increase over the agency’s FY 2004 appropriation of $1.382 billion. It is important to note that from FY 1999 through FY 2004, NIMH received increases that lagged behind the increases received by many of the other NIH institutes. Furthermore, the increase proposed by the Administration for NIMH for FY 2005 is lower than that proposed for most of the other institutes at NIH. As Congress moves forward with deliberations on the FY 2005 budget, AAGP believes that NIMH should receive a percentage increase that, at the very minimum, is equal to the average percentage increase for the other NIH institutes.
  
  Commendable as recent funding increases for NIH and NIMH have been, AAGP would like to call the Subcommittee’s attention to the fact that these increases have not always translated into comparable increases in funding that specifically address problems of older adults. Data supplied to AAGP by NIMH indicates that while extramural research grants by NIMH increased 59 percent during the five-year period from FY 1995 through FY 2000 (from $485,140,000 in FY 1995 to $771,765,000 in FY 2000), NIMH grants for aging research increased at less than half that rate: only 27.2 percent during the same period (from $46,989,000 to $59,771,000).
  
  AAGP is pleased that NIMH has recently renewed its emphasis on mental disorders among the elderly, and commends the recent creation of a new Aging Treatment and Prevention Intervention Research Branch at NIMH as well as the establishment of an intra-NIMH consortium of scientists concerned with mental disorders in the aging population. However, funding for aging mental health research is still not keeping pace with that of other adult mental health research, and is actually decreasing proportionally when considered in the context of anticipated projections in growth of mental disorders in older persons. For example, the proportion of total NIMH newly funded extramural research grant funding devoted to aging research declined from an average of eight percent from FYs 1995 to 1999 to a low of six percent in FY 2000. To reverse this trend, it will also be important to constitute grant review committees with specialized expertise in geriatrics to ensure a fair review of research proposals. Review committees must take into account knowledge of the unique biological factors associated with the aging brain, the high prevalence of co-occurring medical illnesses, and the specific systems for financing and health services delivery for older Americans. In addition, AAGP would like the scope of this branch increased into a comprehensive aging branch that is responsible for all facets of clinical research, including translational, interventions, and disease-based psychopathology. Further, the branch should be given adequate resources to fulfill its primary mission within NIMH.
  
  In addition to supporting research activities at NIMH, AAGP supports increased funding for research related to geriatric mental health at the other institutes of NIH that address issues relevant to mental health and aging, including the National Institute of Aging (NIA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and the National Institute of Neurological Disorders and Stroke.
  
  Center for Mental Health Services
  It is also critical that there be adequate funding increases for the mental health initiatives under the jurisdiction of the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA). While research is of critical importance to a better future, the patients of today must also receive appropriate treatment for their mental health problems. SAMHSA provides funding to State and local mental health departments, which in turn provide community-based mental health services to Americans of all ages, without regard to the ability to pay. AAGP was pleased that the final budgets for Fiscal Years 2002, 2003 and 2004 included $5 million for evidence-based mental health outreach and treatment to the elderly. However, AAGP is extremely alarmed to see that this program was eliminated in President Bush’s FY 2005 budget proposal. Restoring and increasing this mental health outreach and treatment program must be a top priority, as it is the only Federally funded services program dedicated specifically to the mental health care of older adults.
  
  Originally funded in the FY 2002 Labor-HHS-Education Appropriations (Public Law 107-116), AAGP worked with members of this Subcommittee and its Senate counterpart on this initiative, which was intended as a first step in the effort to curb the projected growth of older adults in America suffering from mental disorders. The House Appropriations Committee Report on FY 2002 Labor-HHS-Education Appropriations states that $5 million should be appropriated for a senior mental health outreach and treatment program within CMHS and that the funds are “intended to begin to address” the predicted increase of older adults suffering from mental illness. Regarding the same program, the Senate Appropriations Committee Report states, “The Committee strongly encourages CMHS to devote additional resources in fiscal year 2002 and subsequent fiscal years to this issue.” Unfortunately, this initiative has not seen the subsequent increases its creators intended when Congress created this program.
  
  Funding for the dissemination and implementation of evidence-based practices in “real world” care settings must be a top priority for Congress. Despite significant advances in research on the causes and treatment of mental disorders in older persons, there is a major gap between these research advances and clinical practice in usual care settings. The greatest challenge for the future of mental health care for older Americans is to bridge this gap between scientific knowledge and clinical practice in the community, and to translate research into patient care. Adequate funding for this geriatric mental health services initiative is essential to disseminate and implement evidence-based practices in routine clinical settings across the states. Consequently, we would urge that the $5 million for mental health outreach and treatment for the elderly included in the CMHS budget for FY 2004 not only be restored, but also be increased to $20 million for FY 2005.
  
  Of that $20 million appropriation, AAGP believes that $10 million should be allocated to a National Evidence-Based Practices Program, which will disseminate and implement evidence-based mental health practices for older persons in usual care settings in the community. This program will be a collaborative effort, actively involving family members, consumers, mental health practitioners, experts, professional organizations, academics, and mental health administrators. With $10 million dedicated to a program to disseminate and implement evidence-based practice in geriatric mental health, there will be an assured focus on facilitating accurate, broad-based sustainable implementation of proven effective treatments, with an emphasis on practice change and consumer outcomes. Such a program should include several development phases including identification of a core set of evidence-based practices, development of evidence-based implementation, and practice improvement toolkits and field-testing of evidence-based implementation. This program will provide the foundation for a longer-term national effort that will have a direct effect on the well-being and mental health of older Americans.
  
  Agency for Healthcare Research and Quality
  One of the most valuable resources in our efforts to improve access to and the quality of geriatric mental health services is the Agency for Healthcare Research and Quality (AHRQ). In recent years the Agency has supported important research on mental health topics including studies on children’s mental health issues, the impact of mental health parity on consumers’ share of mental health costs, improving care for depression in primary care, and cultural issues in the treatment of mental illness in minority populations. This work has led to important contributions to the mental health literature, and the advancement of effective diagnosis and treatment of mental illness. We applaud these efforts and urge the Committee to increase support for the critical work of this Agency.
  
  However, we are concerned that the research agenda of the Agency has not given more attention to geriatric mental health issues. The prevalence of undiagnosed and untreated mental illness among the elderly is alarming. Conditions such as depression, anxiety, dementia, and substance abuse in older adults are often misdiagnosed or not recognized at all by primary and specialty care physicians. There is accumulating evidence that depression can exacerbate the effects of cardiac disease, cancer, strokes, and diabetes. Research has also shown that treatment of mental illness can improve health outcomes for those with chronic diseases. Effective treatments for mental illnesses in the elderly are available, but without access to physicians and other health professionals with the training to identify and treat these conditions, far too many seniors fail to receive needed care.
  
  AAGP believes there is an urgent need to translate findings from aging-related biomedical and behavioral research into geriatric mental health care. By utilizing the resources of the evidence-based practice centers under contract to AHRQ, results from geriatric mental health research can be evaluated and translated into findings that will improve access, foster appropriate practices, and reduce unnecessary and wasteful health care expenditures. We urge the Committee to direct AHRQ to support additional research projects focused on the diagnosis and treatment of mental illnesses in the geriatric population. We also believe a high priority should be given to the dissemination of scientific findings about what works best, to encourage physicians and other health professionals to adopt “best practices” in geriatric mental health care.
  
  Conclusion
  Based on AAGP’s assessment of the current need and future challenges of late life mental disorders, we submit the following FY 2005 funding recommendations:
  
  1. The current rate of funding for aging grants at NIMH and CMHS is inadequate. Funding for NIMH and CMHS aging-related health services grants should be increased to be commensurate with current need -- at least three times their current funding levels. In addition, the substantial projected increase in mental disorders in our aging population should be reflected in the budget process in terms of dollar amount of grants and absolute number of new grants.
  
  2. Previous years’ funding of $5 million for evidence-based mental health outreach and treatment for the elderly within CMHS was eliminated in President Bush’s FY 2005 budget proposal. To help the country’s elderly access necessary mental health care, this funding must be restored and increased to $20 million.
  
  3. A fair grant review process will be enhanced by committees with specific expertise and dedication to mental health and aging;
  
  4. Adequate infrastructure and funding within both NIMH and CMHS to support the development of initiatives in aging research, to monitor the number and quality of applicants for aging research grants, to promote funding of meritorious projects, and to manage those grant portfolios,
  
  5. The scope of the recently formed Aging Treatment and Prevention Intervention Research Branch at NIMH should be increased to include all relevant clinical research, including translational, interventions, and disease-based psychopathology, and must receive NIMH’s full support so it may fulfill its primary mission.
  
  6. AHRQ should undertake additional research projects focused on the diagnosis and treatment of mental illnesses in the geriatric population, and dissemination of information on best practices; and
  
  7. Funding for NIAAA must be increased by at least 20 percent to enable it to undertake more research and collect more data focused on issues such as the link between alcohol use and late-life suicide and the impact of alcohol use across the lifespan.
  
  AAGP strongly believes that the present research infrastructure, professional workforce with appropriate geriatric training, health care financing mechanisms, and mental health delivery systems are grossly inadequate to meet the challenges posed by the expected increase in the number of older Americans with mental disorders. Congress must support funding for research that addresses the diagnosis and treatment of mental illnesses, as well as programs for delivery of geriatric mental health services that increase the quality of life for those with late-life mental illness.
  
  AAGP looks forward to working with the members of this Subcommittee and others in Congress to establish geriatric mental health research and services as a priority at NIMH, CMHS, AHRQ and NIAAA.