Improvement Urged in Care of Older Depressed Patients

Sometimes it takes more than a map to get where you’re going. A new survey of Americans aged 65 and older finds that they are not getting the mental health care they need. That survey, “Silver and Blue: The Unfinished Business of Mental Health Care for Older Adults,” was funded and directed by the John A. Hartford Foundation and released December 13, 2012.

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Of the 1,318 older Americans surveyed, 46 percent of those who were currently receiving mental health treatment said their provider did not follow up with them within a few weeks of starting treatment to see how they were doing. And among all the respondents, very few understood the health risks of depression; only 21 percent had heard that depression is believed to double an individual’s risk of developing dementia, and only 34 percent knew it can double the risk of heart disease.

What might be most discouraging about these results is that 10 years prior, the same organization funded a $10 million depression treatment project—with co-funding from the California Healthcare, Hogg, and Robert Wood Johnson foundations—that demonstrated how to double the benefits of the usual treatment of older adults for depression in primary care practices and laid out the changes needed in the process of depression care to ensure that more elderly patients get better.

But adoption of those methods has been slow. “While we found that some progress has indeed been made over the past decade, especially in the area of reducing the stigma attached to depression and other mental health conditions, we also found stark evidence of how far we still have to go to relieve the suffering of too many older adults and their families,” said Christopher Langston, Ph.D., program director for the foundation.

Multiple Obstacles Limited Efforts

This fits with much of what we know about health system change in general, Langston told Psychiatric News. Several factors play a part in the lack of dissemination and adoption of the collaborative care management program for late-life depression that was developed in that project, known as the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model. Details of the randomized controlled trial that resulted in the IMPACT model were published in the December 22, 2002, JAMA.

Payment methods and teamwork requirements are obstacles to implementation of the model, said Langston. “While the model reduces overall spending, you don’t get paid by insurance for some parts of the model. The involvement of a psychiatrist is important, but it’s principally in a nondirect clinical service role. The psychiatrist reviews cases with the clinical care team and advises them, but can’t bill an insurer for that service. The model also demands a strong team-oriented approach to care, and therefore a highly functioning team. You have to know who is responsible for different functions of the model and how to coordinate their work, a difficult task for many practices.”

For elderly patients, depression may not make its way to the top of the list of concerns. “Elderly patients have more chronic disease, and therefore more doctor visits and more competition for time and attention,” explained Langston. “If you have a patient with arthritis, congestive heart failure, high blood pressure, diabetes, and depression, it gets complicated. And during a brief primary care visit, where attention can be on these other issues, depression can get lost. Treating depression can be an effective means for changing chronic disease outcomes, but it can be hard in a busy private care practice to make it a priority. That’s why you have to have a dedicated staff person in the role of depression manager.”

Answer Is Better, Not More, Treatment

But that’s not to say that an effort to address patients’ depression is not being made: “The rates of people getting prescriptions are high; the patients are not better, but they have been prescribed medications. The problem seems to be not one of initiation of treatment, but of better treatment. The care team needs to follow up, reassess, remeasure the level of depression, and make changes to the treatment plan.”

“The ‘Silver and Blue’ survey shows us that there’s still a lot of room for these effective practices to become common practice,” said Langston. “We can, and must, provide better mental health care for older Americans.”

APA President Dilip Jeste, M.D., the Estelle and Edgar Levi Chair in Aging and director of the Sam and Rose Stein Institute for Research on Aging at the University of California, San Diego, agreed that the survey shows that older adults are not getting the quality of care they need.

“This survey clearly highlights a major problem with our mental health care system,” Jeste said. “Today there are more effective treatments available for depression and many other psychiatric disorders in later life than was the case even a decade ago; yet most patients aren’t receiving adequate treatment. The current training of primary care clinicians as well as other mental health care providers in geriatric psychiatry is embarrassingly limited. The number of specialists in this field is woefully inadequate, and the shortage is only getting worse, with growing numbers of older people.”

Jeste pointed out as well that “considerable research has shown that early treatment and even prevention are not only feasible but also effective in reducing morbidity and mortality in older adults. As a society, it is our responsibility to provide the needed care to older people with mental illnesses—one of the most disenfranchised groups. The good news is that help is available, and we must strive to ensure that the patients receive it.” ■