2007 Appropriations for Mental Health Research and Services (Written Testimony)
Subcommittee on Labor, Health And Human Services, Education, And Related Agencies Committee on Appropriations, U.S. House of Representatives
AAGP Past-President Dan G. Blazer, M.D., M.P.H., Ph.D.
3/30/2006
Summary:
AAGP testimony focuses on fiscal year 2007 appropriations for mental health research and services at the Department of Health and Human Services and addresses the impending public health crisis caused by an unprecedented increase in the burden of mental illness among aging persons, especially among the baby boom generation. The recommendations include:
National Institutes of Health
National Institute on Mental Health
* Increased rate of funding for aging grants and adequate infrastructure to develop 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
* Increase in scope of Aging Treatment and Prevention Intervention Research Branch to include all relevant clinical research, including translational, interventions, and disease-based psychopathology.
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
* Increased funding for the Mental Health Outreach and Treatment for the Elderly program to $20 million.
Health Resources and Services Administration
* Restoration of funding for the geriatric health professions program under Title VII of the Public Health Service Act to FY 2005 levels.
The American Association for Geriatric Psychiatry (AAGP) appreciates this opportunity to present its recommendations on issues related to fiscal year (FY) 2007 appropriations for mental health research and services. AAGP is a professional membership organization dedicated to promoting the mental health and well being of older Americans 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.
AAGP appreciates the work this Subcommittee has done in recent years in support of funding for research and services in the area of mental health and aging through the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA). Although we generally agree with others in the mental health community about the importance of sustained and adequate Federal funding for mental health research and treatment, AAGP brings a unique perspective to these issues because of the elderly patient population served by our members.
AAGP recognizes the Federal budget constraints that the Subcommittee must consider in making allocations. At the same time, it is important to note that research dollars and better trained professionals can help avert a crisis in the delivery of mental health care to the elderly in future generations when more efficient and effective therapies are identified through research. In fact, the New England Journal of Medicine has just published an important study, funded by NIMH, that suggests we can significantly decrease relapse rates in depression – which lead to more physician visits and hospitalizations – by continuing these patients for longer periods on antidepressant medication. In addition, studies of the IMPACT model for treating late-life depression suggest that effective treatment of depression in primary care reduces the cost of general health care in those settings.
Even as we note the important research being doing in the field, there are serious concerns, shared by AAGP and researchers, clinicians, and consumers that there exists a critical disparity between appropriations for research, training, and health services and the projected mental health needs of older Americans. This disparity is evident in the convergence of several key factors:
* 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
* as funding for Federal health research has slowed across disciplines, the allocation of 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.
In this context, it is important to note actions relating to late life mental health addressed by the White House Conference on Aging, which was convened by President Bush in December 2005. Recognizing the current health and mental health needs of older Americans and the challenges awaiting as the Baby Boom generation ages, delegates placed mental health and geriatric health professional training issues at the forefront by voting them among their top 10 resolutions.
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. This year’s loss of all funding for geriatric health professions programs under Title VII of the Public Health Service Act is a stunning blow to this critical need, and AAGP urges the Subcommittee to restore these programs.
Current and projected economic costs of mental disorders alone are staggering. 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. 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. Depression is associated with poorer health outcomes and higher health care costs. Co-morbid depression with other medical conditions affects a greater use and cost of medications as well as increased use of health services (e.g., medical outpatient visits, emergency visits, and hospitalizations). For example, individuals with depression are admitted to the emergency room for hypertension, arthritis, and ulcers at nearly twice the rate of those without depression. Those individuals with depression are more likely to be hospitalized for hypertension, arthritis, and ulcers than those without depression. And, those with depression experience almost twice the number of medical visits for hypertension, arthritis and ulcers than those without depression. Finally, the cost of prescriptions and number of prescriptions for hypertension, arthritis, and ulcers were more than twice than those without depression.
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.
National Institute of Mental Health
In his FY 2007 budget, the President proposed a decrease in funding for the National Institutes of Health (NIH), for the first time in thirty years. This decline in funding is likely to have a devastating impact on the ability of NIH to sustain the ongoing, multi-year research grants that have been initiated in recent years.
AAGP would like to call to the Subcommittee’s attention the fact that, even in the years in which funding was increased for NIH and NIMH, these increases did not always translate 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). Furthermore, despite the fact that over the past five years, Congress, through Committee report language, has specifically urged NIMH to increase research grant funding devoted to older adults, this has not occurred.
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. 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. The Branch should also 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 for the mental health initiatives under the jurisdiction of the Center for Mental Health Services (CMHS) within 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 the last five years have included $5 million for evidence-based mental health outreach and treatment to the elderly. AAGP worked with members of this Subcommittee and its Senate counterpart on this initiative, which is a very important program for addressing the mental health needs of the nation’s senior citizens. 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.
The greatest challenge for the future of mental health care for older Americans is to bridge the 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 2005 be increased to $20 million for FY 2006. 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 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.
The Community Mental Health Services Block Grant Program requires states and territories to include an annual plan for providing comprehensive community mental health services to adults with a serious mental illness and children with a serious emotional disturbance. Experience has demonstrated that states do not make adequate provisions for older adults. AAGP recommends that SAMHSA require these plans to include specific provisions for mental health services for older adults.
Health Resources and Services Administration
Despite growing evidence of the need for more geriatric specialists to care for the nation’s elderly population, a critical shortage persists. For FY 2006, the Congress inexplicably eliminated all funding for the geriatric health professions program under Title VII of the Public Health Service Act. The loss of these programs could have a disastrous impact on physician workforce development over the next decade, with dangerous consequences for the growing population of older adults who will not have access to appropriate specialized care. The geriatric health professions program supports three important initiatives. The Geriatric Faculty Fellowship trains faculty in geriatric medicine, dentistry, and psychiatry. The Geriatric Academic Career Award program encourages newly trained geriatric specialists to move into academic medicine. The Geriatric Education Center (GEC) program provides grants to support collaborative arrangements that provide training in the diagnosis, treatment, and prevention of disease. In FY 2005, these programs were funded at $31.5 million, but, while they were funded in the Senate Appropriations bill for FY 2006, the final legislation followed the House version, which eliminated funding for them. AAGP urges the Subcommittee to restore funding to this program at FY 2005 levels.
The loss of these programs, just as the massive Baby Boomer generation are entering late life, will have a devastating effect on the nation’s ability to provide the kind of health care that will allow these seniors to be independent and productive as they age.
Conclusion
Based on AAGP’s assessment of the current need and future challenges of late life mental disorders, we submit the following FY 2007 funding recommendations:
1. The current rate of funding for aging grants at NIMH and CMHS is inadequate and should be increased to 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. To help the country’s elderly access necessary mental health care, previous years’ funding of $5 million for evidence-based mental health outreach and treatment for the elderly within CMHS must be increased to $20 million.
3. Funding for the geriatric health professions program under Title VII of the Public Health Service Act should be restored to FY 2005 levels.
4. Both NIMH and CMHS must support adequate infrastructure and funding within both NIMH and CMHS to develop 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.
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 appropriate agencies within the Department of Health and Human Services.
DAN G. BLAZER, M.D., M.P.H., Ph.D.
Dan G. Blazer, M.D., M.P.H., Ph.D., is J. P. Gibbons Professor of Psychiatry and Behavioral Sciences and Vice Chair for Education and Academic Affairs at Duke University Medical Center. He is a Professor of Community and Family Medicine at Duke and Head of the University Council on Aging and Human Development. He also serves as Adjunct Professor in the Department of Epidemiology, School of Public Health, University of North Carolina.
Dr. Blazer received his undergraduate degree in biology from Vanderbilt University, his M.D. from the University of Tennessee, and M.P.H. and Ph.D. from the University of North Carolina, Chapel Hill. He served an internship in medicine at the University of Tennessee, a psychiatry residency at Duke and a fellowship in consultation/liaison psychiatry at Montefiore Hospital in Following nine years in academic administration (two as Chair of the Department of Psychiatry and seven as Dean of Medical Education at Duke University School of Medicine), Dr. Blazer returned to teaching, research and practice in July of 1999. He is the author or editor of 30 books, author or co-author of over 150 published abstracts and over 300 peer-reviewed articles. He is also the author or co-author of over 150 book chapters. Many of the book chapters and scientific articles are on the topics of depression, epidemiology, and consultation liaison psychiatry, especially with the elderly.
Dr. Blazer has been the principal investigator on many projects funded by federal grants, state grants and grants funded by private foundations. Most of these research projects have focused on the prevalence of physical and mental illness in the elderly. He also was the original PI of the Duke Clinical Research Center for the Study of Depression in Late Life and has been funded as PI for a number of training grants.
Among the honors received by Dr. Blazer are the receipt of a Research Career Development Award from the National Institute of Mental Health and the Alex Haley National Award in 1985 for his work in gerontology. He was received numerous honors from academic institutions and professional societies. He was elected to the Institute of Medicine, National Academy of Sciences in 1995.
Dr. Blazer is currently past-president of the American Association for Geriatric Psychiatry and chair of the membership committee of the IOM. He has served in numerous other leadership capacities, including Chairman of the Board and President of the American Geriatrics Society, past President of the Psychiatric Research Society. He chaired the Committee for the Institute of Medicine review efforts of the Department of Defense to provide adequate medical care to Persian Gulf War Veterans and the IOM committee on Testosterone Replacement Therapy in the Elderly.
Dr. Blazer is married to Sherrill Walls Blazer (a teacher) and is the father of a thirty-four-year-old son (Trey, a surgery resident) and a thirty-two-year-old daughter (Natasha, a social work student). He is a former medical missionary to the United Republic of Cameroun.
Disclosure Statement
Dan G. Blazer, M.D., M.P.H., Ph.D.
5K01 MH066380-02 (Hybels)
04/01/03 - 01/31/08
5.0% - Sponsor
NIH $96,792
(No Salary Support)
Depression and Physical Functioning in Older Adults
The major goal of this project is to explore the interrelationship of depression and physical functioning in a community sample of older adults over time.
N/A (Schulman)
09/01/04 - 08/31/09
2.0%
NIH
$567,720
Dynamic Outcome Assessment in Multi Center Trials
The overall objective of this Patient-Reported Outcomes Measurement Information System (PROMIS) Network site application is to identify and address challenges to integrating computerized adaptive testing into multi-center trials.
T32 – Research in Late-Life Mood Disorders Pre-Doc and Post -Doc Training Grant
7/01/04 - 6/30-09
NIMH
PI (No salary support)
Approximately $85,000 per year.
American Association for Geriatric Psychiatry
The Geriatric Mental Health Foundation (GMHF), a 501(c)3 charitable foundation of which the American Association for Geriatric Psychiatry is the sole member, provided services in conjunction with a contract granted by the Center For Mental Health Services, SAMHSA in 2003-2004 to the National Mental Health Awareness Campaign. The contract was for the execution of two Roundtable Discussions on Mental Health, Aging, and Stigma, which resulted in the 2006 SAMHSA report on this subject. The GMHF facilitated the Roundtables and writing of the report on behalf of the National Mental Health Awareness Campaign.
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