How Mental Health Care Is Falling Short
Here's what needs to change and how we can get there
(Editor’s note: This story is part of a series for The John A. Hartford Foundation.)
Millions of Americans aged 65+ are struggling with depression, anxiety, schizophrenia or dementia, and the prevalence of depression in older adults is expected to more than double by 2050. Suicide among older Americans is also on the rise.
Unfortunately, the prevalence of mental health concerns among aging Americans does not correlate to high levels of care. Just 10 percent of older adults experiencing mental health issues get the treatment they need due to stigmas toward both mental illness and aging, a lack of specialists trained in geriatric care, high health insurance co-pays and difficulties navigating a complex health care system. This begs the question: What would age-friendly mental health care in America look like, and why is age-specific mental health support so important?
Understanding Mental Health and Aging
Suicide rates among white men 85+ years of age remain one of the highest of any age group (nearly six times the national average), and for the first time in history, women are catching up to them. But while depression is a common part of aging today, it shouldn't have to be. That’s something many aging Americans — and health care workers — don’t understand.
“There is a serious lack of awareness of the mental health needs of older adults,” said gerontologist Brandi Orton, director of government relations and advocacy at St. Barnabas Senior Services in Los Angeles. “Many people just assume it’s normal to be isolated and alone.”
According to Orton, misdiagnosis is a huge concern in geriatric mental health care today. Studies show primary care physicians (those most likely to encounter depressed or anxious older patients) diagnose depression accurately less than one half of the time. A lack of indicators — such as poor performance at work or a decline in social behavior — makes proper diagnosis challenging. Symptoms of depression, which include memory loss, are often misdiagnosed as dementia, a clear sign that age-specific (rather than just age-friendly) mental health care is a necessity.
“Older people have different needs when it comes to mental health support,” says Dr. Dilip Jeste, senior associate dean for healthy aging and senior care and director of the Stein Institute for Research on Aging at the University of California San Diego. “They experience sensory deficits, skin perception issues, mobility issues and memory loss that is not necessarily associated with dementia. They need specialists who understand these issues, and just as importantly, they need specialists who have empathy.”
Yet at the same time the number of aging Americans is increasing, the number of those entering geriatric medicine and geriatric psychiatry is declining.
What Needs to Change — And How
Beyond understanding needs and tailoring care to older adults, the conversation around mental health and aging must change, too. Here's how:
Eliminate the stigma, which remains a huge barrier to seeking mental health support. According to Mental Health America, nearly 65 percent of those 65+ believe it is “normal” for people to get depressed as they grow older. It isn't. To help aging Americans feel more comfortable sharing their struggles, some companies, such as Intermountain Healthcare, have created an interdisciplinary approach to mental and physical health. By making mental health assessment part of a patient’s annual exam, they’ve found that patients are 54 percent less likely to have emergency room visits than depressed patients in non-participating clinics. They also found that patients with depression who were involved with a multidisciplinary clinic saw their health insurance claims decrease by $667 in the year following their diagnosis.
Talk about loss, and support those in transition. “The aging process is an accumulation of loss,” Orton says. “As we move through life, all of us experience the loss of roles we played, people we loved or things that built our identity. One of the root causes of depression in aging is that none of us anticipated that loss was coming. We retire at 65 not realizing we have 30 more years of loss ahead of us. We need early and ongoing support in understanding what aging into our 90s actually looks like.” That means providing mental health support during times of transition throughout life — prior to retirement or entrance into an assisted living community, but also in our 30s, 40s and 50s to prepare us for the changes life brings.
Celebrate the good parts of aging. Just as we acknowledge the losses that occur with getting older, we also need to acknowledge the positive things that come with it. According to Jeste, that means older and younger people need to know the importance of aging-associated wisdom — the increased ability to self-reflect, the willingness to be more accepting of diversity, the compassion one builds as we move throughout life. If society begins to value the attributes that aging brings, we will feel more valued as we gain those attributes, as well. (This Next Avenue article, "Can Wisdom Protect Against Loneliness?" has more details on Jeste's insights and advice.)
Offer medical school incentives to help treat mental illness in older Americans. The number of geriatric specialists is declining at a time we need them most. By 2030, there will be just one geriatric specialist per 6,000 patients with mental health and substance use disorders, according to a 2013 Dartmouth University study.
“It’s easy to invest in physical resources associated with aging and accessibility, but much harder to invest in human capital,” Dr. Ellen Lee, a geriatric psychiatrist at the University of California San Diego says. “We need to find ways to invest in standards of care as much as physical access to it.”
While quality, age-friendly mental health care may be rare, Jeste and Lee feel optimistic about some examples they’ve seen in the San Diego area. In one retirement community, staff members are encouraged to bring their children to work so older people can enjoy their energy. In another, a community horse and other live-in pets help lift residents’ spirits. These types of meaningful, intergenerational exchanges and emotional supports go a long way in improving quality of life and mood levels and do not require advanced training, making the interventions easy to implement in neighborhoods and assisted living communities nationwide.