September 8, 1999

Media Contact: Leslie Franz, (619) 543-6163

(Left to right: Dr. Daniel L. Sewell,  medical director of the Senior Behavioral Health Program at UCSD Thornton Hospital, confers with patient Les Fussel and his wife Marilyn, while Dr. Dilip Jeste, director of Geriatric Psychiatry at UCSD and the Veterans Administration San Diego Healthcare System, observes)

MENTAL ILLNESS AND THE ELDERLY:  THE FORECAST IS "CRISIS"

 Forget about Y2K.  With the new millennium fast approaching, the biggest challenge looming on the horizon might actually be the aging baby boom generation. True to form, this sizable population group will be a force to contend with as it reaches its senior years and begins to experience the disorders associated with older age, including psychiatric illnesses. 

Based on the predicted increase in the incidence of mental health disorders among aging "boomers," along with the sheer size of this group, the number of elderly mentally ill is projected to swell from about four million in 1970 to 15 million in 2030.

In the September Archives of General Psychiatry, mental health experts from around the country warn that "(a) national crisis in geriatric mental health care is emerging.  The present research infrastructure, healthcare financing, pool of mental healthcare personnel with appropriate geriatric training, and the mental healthcare delivery systems are extremely inadequate to meet the challenges posed by the expected increase in the number of elderly with mental illnesses." They also advise that "(t)hrough concerted and timely actions, the upcoming crisis could be converted into an opportunity to improve our understanding as well as management of mental illnesses in the elderly."

"If you look at the current infrastructure for meeting the needs of people over age 65, it is as if mental illness doesn't exist for this population," said Dilip Jeste, M.D., professor of psychiatry and neurosciences at the University of California, San Diego (UCSD) School of Medicine.  Jeste is also Director of Geriatric Psychiatry at UCSD and the Veterans Affairs San Diego Healthcare System.  "In terms of medical services, community services, support systems or training programs for caregivers and geriatric mental health specialists, they are practically non-existent.  In another 10 years we will have a near disaster."

Jeste is the lead author of the national "Consensus Statement on the Upcoming Crisis in Geriatric Mental Health: Research Agenda for the Next Two Decades." 

The authors of the paper recommend that with the projected quadrupling of elderly mentally ill by 2030, an aggressive 15- to 25-year research agenda covering prevention, translational research, intervention research and health services research should be put in place to develop strategies for serving this population, and a nationwide training and education program should be conducted in parallel.

The statement summarizes the findings and recommendations resulting from a workshop on geriatric mental health which focused on the post-war babies born between 1946 and 1964 as a significant population group that will begin to hit age 65 in the year 2011.  Psychiatric illnesses from alcohol dependence and anxiety disorders to schizophrenia and severe depression are a harsh reality among older adults today, and could become a real nightmare with this population surge.

The dramatic increase in the number of older people with mental health needs is not just a factor of the population size, which alone is significant: people over 65 are expected to grow in number from 20 million in 1970 to 69.4 million by 2030, outnumbering people between 30 and 44.

To further compound the problem, the percentage of the population with mental illness is also expected to increase.  There is evidence that this population group has a higher incidence of mental illness than previous generations, including a higher rate of substance abuse, which includes illicit substances, alcohol and prescription drugs.  As better treatment for physical and psychiatric disorders increases longevity for everyone,  the prevalence of these disorders in the older population will continue to be higher.

In addition, as more people live longer there will be an increase in late-onset mental illness, sometimes linked to chronic physical conditions or underlying neurological disorders such as Alzheimer's disease.  According to Jeste, 30 to 50 percent of people who develop dementia also develop a treatable psychosis or depression, which can be the cause of problem behaviors that lead to institutionalization, when caregivers can no longer manage the patient at home.

Jeste notes that some older studies have shown low incidence of mental illness among the elderly, but the studies themselves have been plagued by the use of poor diagnostic tools and some of the other challenges of identifying mental health needs in this population.

"Mental illness still carries a stigma among all age groups, and the elderly are not predisposed to seek help or even acknowledge that they have a psychiatric problem," he said.  "Older people who live alone and have little contact with others are not going to be easily identified as having a mental health disorder.  And, many caregivers and even primary physicians are simply not trained to diagnose and treat mental illness in the geriatric population."

Ageism may also be a factor. Some data show that primary care providers often fail to diagnose such common illnesses as depression in the elderly, with three-quarters of physicians stating in one survey that depression was "understandable" in older persons; and when they do diagnose, they often fail to treat it adequately.

The paper's authors note that ethnic and cultural factors can also play a role in whether an elderly person gets help for a mental disorder.  They suggest that training and education about mental health and the elderly be broadened to include not only health professionals, but law enforcement officers, letter carriers, public workers who come in contact with the elderly, and the community at large so people in need of help can be identified and assisted, even if they do not seek medical care.

The use of drugs to treat mental illness in the elderly also presents problems, the paper suggests.  Drug therapies are for the most part studied in a younger population, so the affects of these approved drugs on older adults is not well understood, particularly when the patient is more likely to be taking multiple medications for other conditions.

Finally, the costs associated with caring for mental illness are a factor.  Medicare and Medicaid coverage for visits, drugs and inpatients stays is limited.  The funding models for health care in general pay little attention to the needs of older adults with mental disorders, and current discussions about reform are not focusing on this issue as a problem that must be solved.

Co-authors of the report were George S. Alexopoulos, M.D., Cornell Medical Center; Stephen J. Bartels, M.D., M.S., Dartmouth Medical School; Jeffrey L. Cummings, M.D., UCLA; Joseph J. Gallo, M.D., M.P.H., Johns Hopkins University; Gary L. Gottlieb, M.D., M.B.A., University of Pennsylvania and Friends Hospital; Charles F. Reynolds, III, M.D., University of Pittsburgh School of Medicine; Barry D. Lebowitz, Ph.D., National Institute of Mental Health; and Maureen C. Halpain, M.S., Barton W. Palmer, Ph.D., and Thomas L. Patterson, Ph.D., all of UCSD School of Medicine.

The work was supported in part by grants from the National Institute of Mental Health and the Department of Veterans Affairs.