Mental Health Care for the “Silver Tsunami”

On January 23 the New England Journal of Medicine published “The Underside of the Silver Tsunami – Older Adults and Mental Health Care.” The article draws on an Institute of Medicine report on the mental health workforce for older adults that Peter Brown, executive director of the Institute for Behavioral Healthcare Improvement, discussed here on Over 65 four months ago.

Currently 5.6 to 8 million over 65ers have mental health or substance-use disorders, a number predicted to reach 10.1 to 14.4 million by 2030. The IOM report tells us that although the number of over 65ers with mental health needs is rapidly increasing, the availability of geriatric psychiatrists is actually going down – 1,800 at present, with only 1,650 predicted for 2030, less than 1 per 6,000 older adults with mental health or substance-use disorders.

When I did my psychiatry training in the late 1960s, we were clearly infected by ageism. Here’s how one of the few geriatric psychiatrists challenged our attitudes:

“You believe the patients easiest to treat and most likely to benefit have the YAVIS (‘Young, Attractive, Verbal, Intelligent, and Successful’) syndrome.” (He was right about our beliefs.) “And you think treating elderly people is a waste of time – that they’re too old to change.” (He was right again – we had a bias against older patients.) “But you’re wrong. Older people know themselves. They know what’s wrong and what they need. If you zero in on what’s important to them and set realistic goals, they’ll make real gains. And the treatment won’t take too long.” (I didn’t know it then, but clinical research and my own practice experience would prove that our teacher was correct in what he told us.)

A combination of continuing ageist attitudes and poor fee-for-service reimbursement has led to the dearth of trained geriatric clinicians. But the national move towards paying clinicians via global budgets for populations will add a new incentive to provide mental health care to the older population. Over 65ers with mental health and substance-use disorders have substantially more medical/surgical treatment and recover more slowly from whatever ails them. Mental health interventions paid for as fee-for-service widgets are compensated poorly, but under global budgets mental health treatment will be valued for the contribution it makes to decreased medical expenditures as well as to overall well-being.

The New England Journal article and the IOM report don’t simply wring their hands about the shortage of trained personnel – they make practical suggestions. I was especially drawn to the suggestion that nonprofessionals could extend the work force and make significant contributions. Some years back I observed this with an over 65er in my practice, who himself suffered from depression. He became a volunteer at a psychiatric hospital where he was able to develop excellent rapport with many older patients with depression. He spoke with them as a peer and told them about his own experience. His volunteer work helped others and helped himself at the same time.

The suggestion that elderly folks could help peers with mental health disorders shouldn’t be surprising. Alcoholics Anonymous has demonstrated the potential power of peer support since Bill W. and Dr. Bob founded the organization in 1935. And more than 10 years ago Georgia pioneered a well-organized peer specialist program for patients with severe mental conditions.

I may be a cockeyed optimist, but I expect that Medicare’s programs of reimbursement for outcomes rather than widgets and patient-centered medical homes and accountable care organizations will lead to increased attention to mental health and substance-use disorders on the part of primary care physicians, nurse practitioners, care managers, and others in the health system who deal with the over 65 population. This is an area where improved care, improved health, and cost containment all track together.

James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard medical School.