Testimony & Statements
AAGP's Recommendations for FY 2002 Appropriations for Late-Life Mental Health Research and Services
Testimony before the Subcommittee on Labor, Health and Human Services, Education & Related Agencies of the House Committee on Appropriations
Stephen Bartels, M.D., M.S.
President, American Association for Geriatric Psychiatry
March 8, 2001
Chairman Regula and members of the Subcommittee, I am Stephen Bartels, M.D., the President of the American Association for Geriatric Psychiatry (AAGP). I thank you for this opportunity to present AAGP’s recommendations on issues related to fiscal year (FY) 2002 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. Our membership consists of over 2000 geriatric psychiatrists as well as other health professionals who focus on the mental health problems faced by senior citizens.
At the outset, Mr. Chairman, I would like to note that this is the first time AAGP has had the opportunity to testify before this Subcommittee, and we greatly appreciate your willingness to hear our perspectives on geriatric mental health funding issues. 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 somewhat unique perspective to these issues because of the aged patient population served by our members.
I join many of the other witnesses here today in thanking 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) and the National Institute on Aging (NIA).
However, I am here today to convey the 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 many older adults remain unmet;
- 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 funds for research that focuses on mental health in the aged, as recently reported by NIMH, is disproportionately low, and woefully inadequate to deal with the impending crisis of mental health in older Americans.
Demographic Projections and the Disparity in Research Funding for Mental Disorders of Aging
As shown in Figure 1 (download figures as a Power Point document), the increase in the number of people over 65 years of age, combined with the increasing prevalence of psychiatric problems in that segment of the U.S. population, will dramatically increase the proportion of older adults with mental health disorders relative to younger adults. Furthermore, older adults account for health care costs that are disproportionately greater than their numbers. This figure also illustrates that the projected proportion of NIMH funding for aging research (based on current funding trends) is drastically below what will be needed to address the projected increase in mental health problems among older persons over the coming decades.
With the "baby boom" generation nearing retirement, the number of older Americans experiencing mental problems 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 disorders. 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 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.
Current and projected economic costs of mental disorders alone are staggering. For example, the direct medical costs of caring for patients with Alzheimer’s disease (many of whom are treated by geriatric psychiatrists) 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. 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, family burden, and over 20 percent greater costs over and above Alzheimer’s alone. 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 service use and costs, 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 illnesses justifies 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. While the funding increases supported by this Subcommittee in recent years have been essential first steps to a better future, a serious and sustained investment in research is necessary to allow continuous progress on the many research advances we made to date. Toward that end, we support the professional judgment of the research advocacy community that a 16.5 percent across-the-board increase in FY 2002 funding for NIH is warranted. In addition, we are pleased that President Bush and HHS Secretary Thompson have expressed support for increased funding for NIH in the coming year.
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 for extramural research on mental health of the elderly. 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).
Figure 2 (download figures as a Power Point document) shows that funding for aging mental health research is 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 Americans.
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 (2000) underscore the prevalence of mental disorders in older persons and provide evidence that research supports the development of effective treatments. These publications by the Federal Government recognize the increasing importance of late life mental illness on our society. In addition, 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. 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 effective models of mental health service delivery for older persons.
Special attention also needs to be paid to investigations of inadequate, 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 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 those of their parents.
Perhaps one of the greatest costs of late-life mental illness is the physical and emotional toll on family members, caregivers, and friends. AAGP would like to express its appreciation and support to you and others in Congress for a new program established and funded for the first time this year: the Family Care Givers Program of the Older Americans Act. This new program provides funding to the States so that they may assist family care givers in obtaining the best, most appropriate care for their loved ones, as well as offering care givers limited, but badly needed respite from their care-giving responsibilities. First year funding of $125,000,000 was authorized and appropriated for FY 2001. AAGP expects the need for these services to grow rapidly in the future and urges the members of the Subcommittee to be responsive to this need as it develops. In addition to caregiver programs and support services, research is needed to fill in the gaps in our understanding of the psychiatric responses of caregivers to the chronic stresses of taking care of older adults with mental illnesses.
In addition to supporting research activities at the NIMH, AAGP supports increased funding for other institutes at the NIH that have some jurisdiction over geriatric mental health including: NIA, National Institute of Neurological Disorders and Stroke, as well as continued 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. As you know, 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. The Labor-HHS conference agreement for FY 2001 increased funding for SAMHSA by about 11.5 percent (from $2,651,342,000 to $2,958,001). AAGP urges the Subcommittee to increase the funds available to SAMHSA for these purposes to keep pace with this demand.
Based on AAGP’s assessment of the current need and future challenges of late life mental disorders, we submit the following recommendations:
- 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 (approximately three times the current funding level). 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;
- A fair grant review process will be enhanced by committees with specific expertise and dedication to mental health and aging; and
- Infrastructure within NIMH is needed that supports the development of initiatives in aging research, monitors the quality and number of applicants for aging research grants, and management of those grants.
In conclusion, AAGP strongly believes that the present research infrastructure, health care financing, and healthcare personnel with appropriate geriatric training, and the mental health delivery systems are grossly inadequate to meet the challenges posed by the expected increase in the number of elderly with mental disorders. The economic impact of the aging baby boom generation on the Medicare and Social Security systems has already become a focus of national dialogue, but that there is another challenge that has not received attention. Because of reduced mortality in older adults with chronic medical disorders, we can expect an unprecedented explosion in the number of people over age 65 with potentially disabling chronic mental illnesses. Congress must continue to support funding for research that addresses the identification, diagnosis, and treatment of mental illnesses, as well as support programs that increase the quality of life for those with late life mental illness.
In closing, I would like to thank the Subcommittee again for the opportunity to testify here today. On behalf of the American Association for Geriatric Psychiatry, we look forward to working with you to establish aging research as a priority at NIMH and at CMHS. I will be happy to answer any questions that you may have.
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