Prevention, Treatment and Intervention for Mental Disorders In Older Persons: Priorities for Health

1
Prevention, Treatment and Intervention for Mental
Disorders In Older Persons Priorities for Health
Policy and Research

• Stephen J. Bartels, MD, MS
• President
• American Association for Geriatric Psychiatry
• and
• Dartmouth Medical School
• June 5, 2001

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Mental Disorders of Aging4 Facts To Guide
Public Policy and Research Development

• 1) Dramatic Recent and Projected Growth
• 2) Major Direct and Indirect Impact on
  Health Service Use and Costs
• 3) We Know Treatment Works
• But A Major Gap Exists Between Mental Health
  Service Need and Service Infrastructure and
  Expenditures

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Mental Disorders of Aging4 Facts To Guide
Public Policy and Research Development

• 4) The Emerging Public Health Crisis An
  Alarming Underinvestment in Knowledge
  Dissemination, Service Development, and Research
  to Meet Future Need

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Mental Disorders of Aging Fact 1

• We Are Facing A Dramatic and Unprecedented Growth
  In the Prevalence of Mental Disorders of Aging

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Estimated Prevalence of Major Psychiatric
Disorders in Younger vs. Older Adults from 1970
to 2030
Jeste, Alexopolus, Bartels, et al., 1999
Archives of General Psychiatry
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Mental Disorders of Aging Fact 2

• The Future Growth in Mental Disorders of Aging
  Will Have a Profound Impact on Direct and
  Indirect Costs for Health Care

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Mental Disorders of Aging Fact 3

• We Know Treatment Works
• But A Major Gap Exists Between Research and
  Practice, and Between Service Need and Service
  Delivery

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Mental Disorders In Older Persons We Know
Treatment Works

• Surgeon Generals Report on Older Adults and
  Mental Health (1999)
• Older Adults and Mental Health Issues and
  Opportunities (Administration on Aging, 2001)

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Case Example Depression and Suicide In Older
Persons

• Age 65 highest suicide rate of any age group
• Age 85 2X the National Average (CDC 1999)
• Over HALF of Older Persons who Commit Suicide Had
  a Visit with their Physician in the Prior Month
  (Caine et al., 1996 Am J Geriatr Psychiatry
  Surgeon Generals Report 1999)
• Depression Associated with Poorer Health
  Outcomes and Higher Health Care Costs
• (Unützer et al., 1997 JAMA)
• Antidepressant Medication and Psychotherapy are
  As Effective in Older Adults as in Younger
  Persons (Surgeon Generals Report 1999)

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Case Example Alzheimers Disease and Associated
Problem Behaviors

• 30-40 Depression, Paranoia, and Agitation
• Caregiver Support and EducationDecreased
  Caregiver Depression and Delay of Nursing Home
  Placement by One Year
• (Mittelman et al, 1993 JAMA)
• Currently Available Medications Can Improve
  Cognitive Functioning and Reduce Symptoms
• (Doody et al, 2001 Neurology)
• Agents Under Development Include Nerve Cell
  Protective Medications and Vaccines
• (Doody et al, 2001 Neurology)

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Yet There is A Major Gap Between Research
Findings on Effective Treatment and Clinical
Practice

• And A Major Gap Between Mental Health Services
  and Expenditures and Service Need

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Falling Through the Cracks

• Under Identification and Undertreatment of Mental
  Health Problems in Older Persons
• Among Older Persons in Need 1 in 5 in Nursing
  Homes and 30 in Community Get Treatment
  (Shea et al., 1994, Health Services Research
  Shapiro, et al., 1986)
• Prevention and Treatment A Gap Between What We
  Know AND What We Do
• A Lack of Trained Providers and A Fragmented
  System of Mental Health Care for Older Persons
• Medicare 50 Copayment for Psychological
  Treatments and No Prescription Drug Benefit

13
Inadequate Workforce of Trained Geriatric Mental
Health Providers

• Current Workforce 2,425 Geriatric
  Psychiatrists
• Estimated Current Need 5,000

Jeste, Alexopolus, Bartels, et al., 1999
Archives of General Psychiatry
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Mental Disorders of Aging Fact 4

• An Emerging Public Health Crisis
• A Major Underinvestment in Mental Health
  Services and Research to Meet Future Need

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Dollars Spent by Medicare for Mental Health and
Substance Abuse in Relation to All Health
Expenditures
4.4
4.0
4.7
CSAT/CMHS Spending Estimates Project
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Expenditures on NIMH Newly Funded Grants
9
8
7
8
8
6
NIMH, 2001
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Projected Prevalence Research Funding
Psychiatric Disorders Ratio age 65/age
18-64 (1990 6.1 / 21.1 Million) (2030 15.2 /
36.5 Million)
Health Care Expenditures Age 65 as Proportion
of Total
Proportion of Population Age 65
of Total Expenditures on Aging NIMH Grants
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An Emerging Public Health Crisis

• Dramatic Recent and Projected Growth with a Major
  Direct and Indirect Impact on Health Service Use
  and Costs
• A Major Gap Exists Between Mental Health Service
  Need and Service Infrastructure and Expenditures
• Alarming Underinvestment in Knowledge
  Dissemination, Service Development,and Research
  to Meet Future Need

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Mental Disorders and AgingPrevention, Treatment
and Intervention Health Policy Priorities

• Medicare Mental Health Parity and Prescription
  Drug Benefit
• State Geriatric Mental Health Services Increased
  Training Capacity
• State Demonstrations Implementation of Best
  Practice Models in Primary and Long-term Care
  and Public Mental Health

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Mental Disorders and AgingPrevention, Treatment
and Intervention Federally Supported Research
Priorities

• NIMH A Geriatric Mental Health InitiativeGoal
  of Increased Funding of Aging Research From 6 ?
  18 of Grants Aging Expertise in Grant Reviews
  Aging Program Leadership
• SAMHSA, CMHS, CSAT, and CSAP State
  Demonstrations Implementation and Dissemination
  of Evidence-based Practices
• AHRQ Mental Disorders of Aging and Quality of
  Medical Care