Expert Panel Calls Dearth of Clinicians to Treat Elderly ‘Emerging Crisis’

Baby boomers aren’t babies anymore.

As more of them pass their 65th birthdays, both the absolute numbers of older people and the proportion with mental health and substance use problems will rise, reported the Institute of Medicine (IOM) in July.

There were 40.3 million people in the United States aged 65 and older in 2010, a figure that will jump to 72.1 million by 2030, according to the U.S. Census Bureau.

Yet despite the scale and inevitability of this onrushing demographic wave, too few psychiatrists and other mental health professionals stand ready to care for its members.

“We’re now at the edge of an emerging crisis,” said Dan Blazer, M.D., a professor of psychiatry and behavioral sciences at Duke University and chair of the IOM panel that produced the report. “The burden of illness among older persons is significant, and the pressures on primary care, nursing homes, and direct care will increase.”

That insight has been visible on the horizon for at least a decade.

A paper published in 1999 by Dilip Jeste, M.D., now president of APA, and others, noted that the Environmental Catchment Area Study in 1991 estimated that 13 percent of the elderly met criteria for mental disorders. However, adding to that figure expected higher generational rates of depression, anxiety, substance use, and dementia would mean that closer to 22 percent of the elderly is likely to have a psychiatric or substance use disorder by 2030, they wrote.

“People are not thinking about this now, but the baby boomers will demand dealing with it,” said geriatric psychiatrist Laurence Miller, M.D., medical director of the Division of Behavioral Health Services in Arkansas and a clinical professor of psychiatry at the University of Arkansas for Medical Sciences in Little Rock. Miller was not involved with the IOM study.

“The behavioral health workforce is insufficient now,” said Miller. “As the elderly population explodes, the shortage will only get worse.”

Those inadequacies are excaerbated by “a conspicuous lack of national attention” to the problem, said the report. A “disconcertingly small” number of providers are going into geriatrics now, “dwarfed by the pace at which the population is growing.”

Reimbursement Levels Inadequate

“Most professionals who work with older adults say they like their work, but reimbursement remains a problem,” said Blazer. “It just doesn’t pay as well as, say, child psychiatry, especially under Medicare.”

Professional training connecting mental health and geriatrics is inadequate, the panel’s report emphasized.

The elderly population has specific needs, Miller noted. They present with general medical as well as psychiatrically complicated conditions, yet geriatric fellowships go unfilled.

“So because there are not enough geriatric psychiatrists, we have to think creatively,” Miller told Psychiatric News. “We have to take a population-based, rather than a patient-based approach.”

Yet delivery and reimbursement systems have so far not adjusted to this reality.

For instance, some evidence-based models of depression treatment rely on care managers to coordinate the efforts of primary care physicians, psychiatrists, and social workers. However, Medicare currently does not pay for the care managers’ time, despite their demonstrated value. Nor does the system reimburse a psychiatrist who consults with the care manager or the primary care clinician but does not see the patient directly, said Blazer.

The Centers for Medicare and Medicaid Services is exploring alternative models of care but has not changed its policies yet, he pointed out.

Government Efforts Lack Coordination

Finally, attempts to expand and improve the workforce to care for older people with mental health or substance use problems are seriously hampered by a dispersal of responsibility across numerous federal government agencies, said the report.

For instance, the Health Resources and Services Administration is supposed to promote health care workforce development, but its geriatric training programs include nothing on mental health or substance abuse conditions, according to the report. Only a small part of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) budget is aimed at the elderly, and the agency has eliminated the Older Adults Targeted Capacity Expansion grants program.

“And it’s very telling that the National Institute on Aging didn’t see mental health and substance abuse issues among the elderly as their area of interest,” Miller said.

The previously authorized National Health Care Workforce Commission could use existing law and serve as a central coordinating body for federal efforts—if it were funded by Congress, said the report. Until then, the secretary of Health and Human Services should designate a responsible entity to do so.

How soon that might happen is unclear, said Blazer. “But we have made the recommendations to get the process started.”

“I’d like to see SAMHSA take the lead and work with other agencies, but such a coordinated federal response seems unlikely to happen soon,” Miller suggested.

“As a geriatric psychiatrist, I strongly support the findings and recommendations of this new IOM report on aging and mental health and substance use disorders,” said Jeste, a professor of psychiatry and neurosciences at the University of California, San Diego, in a recent statement. “The American Psychiatric Association hopes that necessary changes are implemented soon to provide badly needed care for our elderly patients, particularly those with financial needs who are among the most disenfranchised sectors of our society.”

“The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?” is posted at www.iom.edu/Reports/2012/The-Mental-Health-and-Substance-Use-Workforce-for-Older-Adults.aspx.