FY 2003 Appropriations for Mental Health Research and Services
Subcommittee on Labor, Health and Human Services and Education of the House Committee on Appropriates
The American Association for Geriatric Psychiatry
5/9/2002
The American Association for Geriatric Psychiatry (AAGP) appreciates this opportunity to present its recommendations on issues related to fiscal year (FY) 2003 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 would like to thank the Subcommittee for its continued strong support for increased funding for the National Institutes of Health (NIH) over the last several years, particularly the additional funding you have provided for the National Institute of Mental Health (NIMH), the National Institute on Aging (NIA), and the Center for Mental Health Services (CMHS) within 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.
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 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 mental health needs of most older adults remain unmet;
* a lack of quality education programs exists to train sufficient numbers of geriatric mental health providers;
* a major gap exists between research 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 on mental health and aging 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 experiencing 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 action must be taken now to avert serious problems in the near future. While many forms 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 are staggering. For example, the direct medical costs of caring for patients 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 other expenses 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 caring for 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, combined with Alzheimer’s disease, can increase the cost of treating these patients by more than 20 percent.
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. 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. Older adults have the highest rate of suicide rate compared to any other age group.
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 supports the development of effective treatments. These reports summarize research findings showing that treatments are being developed and tested that are effective in relieving symptoms, improving functioning, enhancing quality of life, including preliminary findings suggesting 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 focusing 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 research agenda focusing on health services research on mental health and aging 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 investigations of inadequately or poorly studied, serious late-life mental disorders since 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 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 those of their parents.
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
The President’s proposed increase of $3.7 billion (15.7 percent) over FY 2002 represents the final step in the doubling of the NIH budget between FYs 1999 and 2003. This increase would bring the NIH budget to a level of $27.3 billion. While AAGP applauds the President’s commitment to double the NIH budget, we are concerned that the proposed budget increase for NIMH lags far behind the nearly 14 percent increase proposed for other NIH institutes. For NIMH, the President is proposing $1.359 billion for scientific and clinical research, a $105 million increase over the agency’s FY 2002 appropriation of $1.254 billion, amounting to an increase of 7.8 percent. As Congress moves forward with deliberations on the FY 2003 budget, AAGP believes that NIMH should receive a percentage increase that, at the very minimum, is at least equal to the average percent increase for the other NIH institutes.
Commendable as recent funding increases for NIH and NIMH have been, 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 in recent months NIMH has renewed its emphasis on mental disorders among the elderly, and commends the creation 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. It is likely that one reason for the decline in funding of new grants is due to the lack of grant review committees at NIMH with specific expertise in aging. Grant review committees with specialized expertise in geriatrics are needed to assure fair review of research proposals that take into account knowledge of the unique biological factors associated with the aging brain, the universal presence of co-occurring medical disorders, and different nature of financing and health service delivery for older adults.
In addition to the current research conducted at NIMH focusing on basic research on the causes and treatments of mental health problems in older persons, AAGP recommends a specific focus on research to discover the most effective approaches to changing provider practice, improving the quality of geriatric mental health practice in the community, and measuring outcomes of quality care.
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 CMHS within SAMHSA. While research is key 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 Labor-HHS conference agreement for FY 2002 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 first step in addressing the mental health needs of the nation’s senior citizens.
Funding for the dissemination and implementation of evidence-based practices in “real world” usual 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 findings and clinical practice in usual care settings within the community. The greatest challenge for the future of mental health care for older Americans is to bridge this gap. Adequate funding is essential to disseminate and implement evidence-based practices in routine clinical settings across the states.
We would urge that the $5 million for mental health outreach and treatment for the elderly included in the CMHS budget for FY 2002 be increased to $20 million for FY 2003. 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 effort will be aimed at synthesizing and developing optimal methods for disseminating and implementing proven treatments for common disorders such as depression, Alzheimer’s disease, psychosis, and alcohol and medication misuse, as well as models of effective mental health service delivery in the community, primary health care, and long-term care settings. 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 represents important contributions to the mental health literature and to 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.
We are concerned that AHRQ’s research agenda has not given more attention to geriatric mental health issues. The prevalence of undiagnosed and untreated mental illness among the elderly is alarming. Affective disorders, including depression, anxiety, dementia, and substance abuse, are often misdiagnosed or not recognized by primary and specialty care physicians in their elderly patients. There is accumulating evidence that depression as a co-occurring condition with a variety of chronic diseases can exacerbate the effects of cardiac disease, cancer, strokes, and diabetes. Research has 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, most seniors fail to receive needed care.
AAGP believes there is an urgent need to translate advancements from biomedical and behavioral research in geriatric mental illness to clinical practice. By utilizing the resources of the evidence-based practice centers under contract to AHRQ, results from geriatric mental health research can be assessed 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 the Agency 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 in the diagnosis and treatment of geriatric mental illness to ensure that physicians and other health professionals have access to significant advancements in care.
Conclusion
Based on AAGP’s assessment of the current need and future challenges of late life mental disorders, we submit the following recommendations:
1. The current rate of funding for aging grants at NIMH and CMHS is inadequate. Funding for NIMH and CMHS aging research grants should be increased to be commensurate with current need (at least three times their current funding levels), and CMHS must initiate a program to disseminate and implement evidence-based mental health practices for older adults in usual care settings. In addition, the anticipated projected future increase in mental disorders among our aging population in terms of dollar amount of grants and absolute number of new grants should be built into the budget process;
2. A fair grant review process will be enhanced by committees with specific expertise and dedication to mental health and aging;
3. Infrastructure and reporting mechanisms within NIMH and CMHS are essential to support the development of initiatives in aging research, monitor the quality and number of applicants for aging research grants, and management of those grants. Those individuals in the Office of the Director of NIMH and in the Office of the Director of CMHS who are designated to oversee the aging research agendas and initiatives for these two agencies should provide regular reports to Congress to ensure accountability; and
4. AHRQ should undertake additional research projects focused on the diagnosis and treatment of mental illnesses in the geriatric population.
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 and AHRQ.
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