Geriatric Psychiatry Can Be in Vanguard of Change

“Geriatric psychiatry is a long-term growth industry,” said Charles Reynolds III, M.D., as he stepped into the role of president of the American Association for Geriatric Psychiatry (AAGP) at the association's 2009 annual meeting in March in Honolulu. He was only half joking.

Reynolds is the University of Pittsburgh Medical Center endowed professor of geriatric psychiatry. He also is a professor of neurology and neuroscience and senior associate dean of the School of Medicine, and a professor of behavioral and community health sciences at the University of Pittsburgh Graduate School of Public Health. His presidential address was titled“ Tipping Point: The Future of Psychiatry.” In it, he argued that the profession of psychiatry is on the brink of dramatic changes and growth and that geriatric psychiatry is well positioned to take the lead in greater collaboration with neurology, internal medicine, and other disciplines and to translate research into public health strategies.

“The strategies that we [geriatric psychiatrists] have developed ... have enormous relevance to the future of psychiatry at large,” Reynolds stated.

Psychiatry underwent a previous “tipping point” in the 20th century, according to Reynolds, when randomized, controlled clinical trials elevated the standard for clinical evidence and fundamentally changed practice. Now, psychiatry is at another tipping point at which transformation of the entire profession is imminent. He pointed to areas of change to which psychiatry must adapt: strengthening psychiatry as a “discipline of brain science” and translating evidence into practice, building a better business model to pay for its mission, placing more emphasis on early and continuous multidisciplinary training, and improving the “academic infrastructure.” The future of psychiatry, said Reynolds, will progress in the directions of both clinical neuroscience and public health, especially the prevention of mental illness on a population scale.

Some psychiatrists had suggested that once the etiology of a disorder was ascertained, the disorder was no longer in the realm of psychiatry and fell into another medical specialty. “That's not the case any more,” Reynolds said, thanks to the advances in neurosciences that increasingly reveal the causes and pathology of psychiatric illnesses. “The boundary between psychiatry and neurology is increasingly artificial. Our foci are complementary.”

However, Reynolds does not think that psychiatry and neurology will merge as one discipline, but that they will become more closely intertwined. One of the growth strategies for psychiatry, he suggested, is to “re-integrate the education of psychiatry and neurology on multiple levels. Partnerships in undergraduate and graduate education would be to the benefit of both specialties.”

Despite the scientific advances, Reynolds pointed out that society's psychiatric needs are far greater than psychiatry's current capacity to treat all patients effectively. Among the key weaknesses in the profession, he noted, are “inadequate investment in studies of etiology, pathophysiology, and rational—theoretically based, pathophysiologically informed—prevention and treatment” and “inequities in the delivery of mental health services to disadvantaged populations.”

“There is a good but not an excellent armamentarium for assessment and treatment of mental illness,” he said. Psychiatry needs more integrated approaches in research and funding and increased“ institutional support for junior faculty and infrastructure of academic medicine.”

The coexistence of neurologic and psychiatric illness burden is especially common in geriatric psychiatry. This allows geriatric psychiatrists to provide a model of synergy in multidisciplinary teams for the rest of psychiatry, according to Reynolds.

“Our training is based in clinical neuroscience. We are at the convergence of psychiatry, neurology, and internal medicine,” he said, pointing out that geriatric psychiatrists are well versed in the language of neurologists while taking a holistic approach to treat the emotional and psychiatric issues of patients, caregivers, and families.

In an interview with Psychiatric News, Reynolds discussed the progress made in the research and application of psychosocial interventions for depression and anxiety in not only geriatric patients but also in the caregivers of these patients. Evidence has emerged to support interpersonal therapy, problem-solving therapy, and cognitive-behavioral therapy in helping patients and caregivers cope with the difficulties of mental illnesses such as dementia. During his term as the association president, one of the agendas for AAGP will be to give more prominence to psychosocial research in educational programs.

A lack of new blood in the academic sphere of psychiatry concerns Reynolds.“ Our training needs, but often lacks, a robust public health dimension,” he observed. “In some ways, we have a 'professional inferiority complex.'... We're not always as proud as we should be or deserve to be for the work we do.”

Geriatric psychiatry is facing a serious shortage of new practitioners and researchers, Reynolds told Psychiatric News. “This is a relatively small field.... There are about 1,500 geriatric psychiatrists nationally.” In fact, there is a similar shortage of geriatricians across the country, he noted.

Reynolds was a member of the Committee on the Future Health Care Workforce for Older Americans organized by the Institute of Medicine. The committee released a report in April 2008 forecasting dire shortages in the health care workforce caring for the aging population and called for an urgent expansion and fundamental reform in the recruitment, training, and retention of geriatric health care providers, including those in geriatric psychiatry.

Geriatric psychiatrists face many challenges, one of which is the lack of reimbursement for care coordination, Reynolds noted. Furthermore, as the number of dementia patients balloons with the aging population, the workforce shortage will hit caregivers hard, ranging from family members to direct care workers in nursing homes and long-term-care facilities. Another challenge facing the subspecialty is the barrier of stigma, especially among minority elderly patients, since the proportion of elderly minorities will certainly increase in the next decades. “The need for culturally sensitive care cannot be overstated,” he commented.

As a member of the DSM-V Task Force and Sleep/Wake Disorders Work Group, Reynolds is convinced that prevention of mental illness in individuals and in populations will take a much larger role in the coming years. This area of research and practice is especially relevant for aging adults, with exciting new evidence related to the prevention of geriatric depression and dementia that links psychiatry closely to cardiovascular health and other disciplines.

Reynolds emphasized that training for future geriatric psychiatrists requires a broader view of public health. “This is a new and exciting time. The clinical needs are great. We need to properly incentivize young people to enter and stay in geriatric psychiatry.”

When asked about his outlook for the future of AAGP, Reynolds concluded,“ I am optimistic. We can help the nation age successfully.”▪