Depression is the most common psychiatric illness faced by seniors (CDC, 2008b), with 19% of older adults suffering from it. However despite its high treatability, many older adults remain ill. In fact, almost two thirds of those seniors suffering from depression do not receive necessary treatment (APA, 2005), and this can have very severe consequences.
Depression interferes with social interactions, as well as activities of daily living, and symptoms can last for prolonged periods of time. Consequences are huge and range from the psychological effects to a suffering individual, all the way to the financial burden on taxpayers through the medical bills of low-income sufferers of a disease that is comorbid with depression. When broken down by age, ethnicity and gender, the most likely individuals to attempt and die by suicide in the United States, are white males over the age of 65 (CDC, 2008a). According to the CDC, on average, an elderly person dies by suicide every 1 hour and 37 minutes. Additionally, of seniors who die this way, 20% had seen a doctor the same day, 40% within a week and 70% in the same month, this clearly demonstrates missed opportunities for intervention (AAGP, 2011). Untreated depression can also have profound affects on physical health, lowering immunity and compromising an individual’s ability to overcome infections (APA, 2005). Depression frequently accompanies heart disease, diabetes and stroke (Frederick et al, 2007), all of which significantly increase healthcare costs. Seniors living with depression use more medications and visit doctors and hospitals far more frequently than healthy individuals, additionally hospital stays are longer and outpatient charges greater (CDC, 2008a). The quality and availability of services is currently such that many depressed seniors end up unnecessarily in nursing or state psychiatric hospital, this is far more expensive for taxpayers than targeted prevention and intervention strategies.
Current mental health policy in the United States is incomprehensive and fragmented between different levels of government and various service providers, with many individuals ultimately falling through the cracks. There is not one set strategy for dealing with depression in older adults and thus care can differ widely depending on where an individual is located. At a most basic level, individuals have access to treatment but many are not aware they qualify, or cannot afford associated costs. Significant barriers exist in the form of stigma and a lack of knowledge, with many individuals perceiving depression as a normal part of aging or untreatable. Little policy action has taken place to help older adults who lack access to services and a crisis of insufficient specialized professionals has remained ignored. These problems will only get worse as our population continues to age. It is predicted that the number of seniors with a major psychiatric disorder is estimated to double, from 7 million to over 15 million (Jeste et al, 1999). A particularly noteworthy trend identified by Scogin (2009), suggests that the Baby Boom cohort are showing signs of depressive disorders in far higher numbers than previous generations.
Increased Number of Professionals:
As the Affordable Care Act promises greater access to mental health services and depression screening as part of the Medicare Annual Wellness Visit from 2014, there is great concern if the manpower exists to handle potentially large numbers of new clients (Abrams and Young, 2006). There is a significant shortage in the number of geriatric mental health professionals. Around 2,500 psychiatrists have taken the necessary study to focus on the treatment of older adults, however need exists for around 5000 (AAGP, 2011). In spite of the large number of education opportunities to pursue this career path, during the academic year 2001-2002, only 61% of university positions were filled (Warshaw et al, 2002). This shows that the lack of trained professionals is not caused by an absence of learning opportunities but by an insufficient number of students wanting to pursue this career.
Specializing in geriatric psychiatry involves one extra year of study and this specialized training does not lead to the higher salaries that the same level of advancement in another field would (Warshaw et al, 2002). The Caring for an Aging America Act (Senate Bill 1095) was reintroduced to congress in 2011, but was unsuccessful. The purpose of this bill was to provide access to specific loan repayment programs to those who choose to specialize in geriatrics by labelling the field a primary health care service (AAGP, 2011). Work also needs to be done to equip individuals who do not specialize in the field of gerontology with basic geriatric mental health skills.
There is also evidence to support the creation of a community health workforce of individuals who don’t have a formal medical or psychology education but can work supervised by a specialist. These individuals would receive sufficient training to be able to provide screening services, brief intervention or interim treatments and also specialize in small amounts of preventative work. Trials from other countries support the effectiveness of this method for sufferers of depression. For example, a randomized trial in Goa demonstrated the effectiveness of lay health counsellors providing stepped care screening and also some treatment, in collaboration with primary care physicians (Bartels and Naslund, 2013).
There are significant barriers to treatment faced by many seniors. Stigma remains a significant problem surrounding depression and particularly in the elderly. Many individuals, including seniors themselves, view depression as an unavoidable part of aging and not something treatable. In addition, many seniors who may contemplate seeking assistance lack access to transportation to reach help, this isolation can be both a trigger for depression and a significant barrier to having it treated.
Particularly in rural areas, it is important that strategies are created to reach seniors in their own homes. A potential method would be to take advantage of seniors increasing use of the Internet, by creating online mobile health systems that detect depression, provide advice for prevention, and assist individuals seeking help when they need it. Telephone based therapy is another method to explore for mild cases of depression, when seniors are unable to visit a healthcare facility. The Pennsylvania State-wide Depression Education and Awareness Campaign is a replicable and successful outreach model that distributes awareness packets to seniors, holds depression screenings during local events and provides web-based services to promote mental health (DHHS, 2007).
Good prevention techniques are another important part of effective outreach and would incorporate campaigns to educate the population on risk factors for depression, the effectiveness of treatment and how to get help. Alert and Alive is a New York City program that help seniors feeling sad, loss or stressed in the community (DHHS, 2007). These outreach activities include mental health courses and activities, or simply a safe space to discuss thoughts or concerns, in the hopes of preventing cases of full-blown depression.
Integrated Healthcare System
The majority of seniors with depression also suffer from other chronic illness (APA, 2005). A fractured healthcare system with work split between Federal, State, and Local mental health, general health, and aging agencies, has meant inconsistent and ineffective treatment for seniors with depressive disorders. Currently many need to visit a variety of providers and receive several different types of care, in order to get all of the assistance that they need. The Administration on Aging (2001) found that many older adults end up frustrated and feeling powerless, due to this fragmented system. Physical symptoms are also easier to identify, and so individuals often end up only seeking help for those when forced to choose.
In 2007, the APA established the Integrated Health Care for an Aging Population Initiative, the goal of which was to make recommendations on how mental health providers could work together with specialists dealing in other types of health care for seniors (APA, 2008). A clear and comprehensive strategy was formulated by this task force and provides an outline of necessary changes that should be implemented in every State. The purpose of related legislation would be to ensure that mental health care becomes a key part of all primary care in any location where seniors are present.
The integrated care model involves collaboration at all stages: assessment, treatment planning and implementation and also during the evaluation of outcomes (APA, 2008). The first step towards this goal is the creation of teams of professionals who deal with different aspects of seniors care, e.g. social workers, psychiatrists, doctors and home health aides. At the assessment stage, a representative should be able to determine the various needs of any patient; this information is then shared with an entire team of professionals who add their opinions on the proposed course of treatment. Individual members then provide care within their area of expertise, whilst also reporting back on how successfully their treatment is progressing. The team would then collaborate using this information to either amend the course of action or continue (APA, 2008).
Abrams, R.C., Young, R.C. (2006). Crisis in access to care: Geriatric psychiatry services unobtainable at any price. Public Health Report 121, 646–649. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781905/
Administration on Aging. (2001). Older Adults and Mental Health: Issues and Opportunities. Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://www.globalaging.org/health/us/mental.pdf
American Association for Geriatric Psychiatry. Legislative and Regulatory Agenda 2011- 2012. Retrieved from http://www.aagponline.org/clientuploads/LegislativeAgenda2011FINAL.pdf
American Psychological Association Office on Aging (2005). Psychology and Aging: Addressing Mental Health Needs of Older Adults. American Psychological Association. Retrieved from http://www.apa.org/pi/aging/resources/guides/aging.pdf
American Psychological Association Office on Aging (2008). Blueprint for Change: Achieving Integrative Health Care for an Aging Population. Retrieved from http://www.apa.org/pi/aging/programs/integrated/integrated-healthcare-report.pdf
Bartels, S.J., Naslund, J.A. (2013) The Underside of the Silver Tsunami--Older Adults and Mental Health Care. The New England Journal of Medicine, 368(6): 493-6. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1211456
Centers for Disease Control and Prevention and National Association of Chronic Disease Directors (2008a). The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? National Association of Chronic Disease Directors. Retrieved from http://www.cdc.gov/aging/pdf/mental_health.pdf
Centers for Disease Control and Prevention and National Association of Chronic Disease Directors (2008b). The State of Mental Health and Aging in America Issue Brief 2: What Do the Data Tell Us? National Association of Chronic Disease Directors. Retrieved from http://www.cdc.gov/aging/pdf/mental_health_brief_2.pdf
DHHS National Association of Mental Health Planning and Advisory Councils (2007). Older Adults and Mental Health: A Time for Reform. Center for Mental Health Services, Substance Abuse and Mental Health. Retrieved from http://www.namhpac.org/PDFs/01/olderadults.pdf
Frederick, J.T., Steinman, L.E., Prohaska, T., Satarino, W.A., Bruce, M., Bryant, L., . . . . . . . ., Snowden, M. (2007) Community-based treatment of late life depression: an expert panel–informed literature review. The American Journal of Preventative Medicine 33(3), 222-49. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17826584
Jeste, D., Alexopoulos, G. S., Bartels, S. J., Cummings, J. L., Gallo, J. J., Gottlieb, G. L., . . . ., Lebowitz, B. D. (1999). Consensus statement on the upcoming crisis in geriatric mental health: Research agenda for the next 2 decades. Archives of General Psychiatry, 56, 848-853. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12884891
Scogin, F. (2002). Depression and suicide in older adults resource guide. American Psychological Association. Retrieved from http://www.apa.org/pi/aging/resources/guides/depression.aspx
Warshaw, G. A., Bragg, E. J., Shaull, R. W., & Lindsell, C. J. (2002). Academic geriatric programs in U.S allopathic and osteopathic medical schools. Journal of the American Medical Association, 288(18), 2313-2319. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12425709