Mental and substance use disorders are major impediments to living well in old age. They cause considerable personal suffering and make it difficult for older people to achieve their potential in old age. This is a population in critical need of education, targeted prevention and early intervention.
Untreated mental and substance use disorders among older adults exacerbate health conditions, decrease life expectancy, and increase overall healthcare costs. 1, 2, 3
Mental disorders, particularly depression and anxiety, are major contributors to—and are exacerbated by—social isolation, which results in diminished quality of life, further barriers to intervention and premature institutionalization. 4
Older adults have one of the highest suicide rates in the nation, completing suicide nearly 30% more than the general population. In particular, white males 85 and over complete suicide at nearly four times the rate of the general population. As life expectancy increases, it is reasonable to anticipate that increasing numbers of older adults will probably die by suicide. 5
- Depression, one of the conditions most commonly associated with suicide in older adults, is a widely under-recognized and undertreated medical illness. 6
- Many older adults who die by suicide — up to 75 percent — visited a physician within a month before death. 7
Untreated mental disorders among both older adults with physical disabilities and family caregivers are a major cause of avoidable placements in institutional settings. 8, 9, 10
The good news is that treatment works.
There are effective, evidence-based interventions that can improve the quality of life of older adults with mental and substance use disorders, including dementia.
Unfortunately, mental disorders among older adults are all too often neglected in our society due to the following factors:
- Ageism – the false belief that mental disorders, particularly depression and dementia, are normal in old age. This belief is held not only by older adults, family members, and service providers, but is also rampant within society at large.
- Stigma – the shame of having a mental disorder. Stigma discourages older adults and their family members from acknowledging mental health needs and pursuing treatment, ultimately decreasing quality of life.
- Ignorance – the lack of education and understanding regarding age related vulnerabilities and impact of mental disorders on older individuals. Without education on the diversity and severity of behavioral conditions in later life, problems are not identified, treatment is not accessed and recovery is not obtained.
It is imperative that we translate research findings into practice, invest in evidence based practices and develop geriatric mental health workforce capacity and competency to meet the growing and unique needs of late life mental illness and substance use disorders. These investments are needed to improve the lives of older adults and their families and reduce overall costs to the healthcare system. In addition to the moral obligation we have to our older citizens, optimizing late life behavioral health benefits our families and communities in multiple ways:
- Healthy older adults make valuable contributions as employees in our workforce and as volunteers in communities and organizations with need.
- Family members can remain engaged in the workforce and personal pursuits as they do not need to prematurely leave the workforce to care for older loved ones with functional and health declines attributable to untreated behavioral health disorders.
- Unnecessary, premature and costly institutionalization can be delayed or avoided and caregiver burden and symptoms of depression reduced with effective programs of counseling and support for caregivers of persons with dementia. 11 ,12
Older Adult Mental Health Needs
- The population of older adults in the U.S. will nearly double over the next 20 years. More importantly, adults 65 and older will increase from 13% to 20% of the population, roughly equal to the population of children under age 18. If the prevalence of mental disorders among older adults remains unchanged, over the next two decades the number of older adults with mental and/or substance disorders will nearly double from about 8 million people to about 14 million people. That is staggering growth, and our service systems are not prepared. 13, 14
- At least 5.6 million to 8 million older adults – nearly one in five - have one or more mental health or substance use conditions which present unique challenges for their care. 15
- Unfortunately, fewer than 40% of older adults with mental and/or substance use disorders get treatment. Of those who receive treatment, most go initially to primary care physicians, who provide minimally adequate care less than 15% of the time. 16
Priorities for Addressing the Mental Health Needs of Older Adults
One of the key solutions that would begin to address the needs of older persons with mental health conditions would be to include clinical mental health counselors as recognized Medicare providers. This specific action would go a long way to addressing the mental health workforce shortage and related problems we are witnessing in the older adult sphere.
More on what you can do to make this legislative measure happen will appear in our next blog, as well as other solutions you could support to improve mental health services
1 U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, MD: 1999).
2 Husaini, B,A, et. Al (2000). Prevalence and cost of treating mental disorders among elderly recipients of Medicare services. PsychiatricServices, 51, 1245-1247.
3 Katon,W., Ciechanowski, P. (2002). Impact of major depression on chronic medical illness. Journal of Psychosomatic Research, 53, 859-863.
4 Warner, J. P.(1998) Quality of life and social issues in older depressed patients. International Clinical Psychopharmacology, 13, Supplement 5, S19–24.
5 Mortality Reports. National Center for Injury Prevention and Control. Centers for Disease Control and Prevention.
6 Blazer, D. (2009). Depression in late life: Review and commentary. FOCUS, 7, 118-136.
7 Luoma, J., Martin, C., & Pearson J. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 159 (6), 909-916.
8 Grabowski, D.C., Aschbrenner, K.A., Feng, Z., & Mor, V. (2009). Mental illness in nursing homes: Variations across states. Health Affairs, 28 (3), 689-700.
9 Dorenlot P, Harboun M, Bige V, Henrard JC, Ankri J. (2005). Major depression as a risk factor for early institutionalization of dementia patients living in the community. Int J Geriatric Psychiatry, 5, 471-8.
10 Buhr, G., Kuchighatla, M., & Clipp, E. (2006). Caregivers' reasons for nursing home placement: Clues for improving discussions with families prior to the transition. The Gerontologist, 46, 52-61.
11 Mittelman MS, Haley WE, Clay OJ, Roth DL. Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology. 2006 Nov 14;67(9):1592-9.
12 Substantial literature confirms that family caregivers are the primary source of care in the community for persons with dementia and behavioral disturbances of persons with dementia are associated with caregiver depression including: Covinsky KE, Newcorner R, Fox P, et al. Patient and caregiver characteristics associated with depression in caregivers of patients with dementia. J Gen Intern Med. 2003;18(12):1006-1014.
13 Grayson, V., and Velkoff, V., (2010), THE NEXT FOUR DECADES, The Older Population in the United States: 2010 to 2050, Current Population Reports, P25-1138, U.S. Census Bureau, Washington, DC. Retrieved from: http://www.census.gov/prod/2010pubs/p25-1138.pdf.
14 U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, MD: 1999).
15 Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: National Academies Press.
16 Wang PS, Lane M, Olfson M, Pincus H, Wells KB, Kessler RC (2005). Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry. 62: 629-640.