Mental and Behavioral Health and Older Americans
As America’s population ages, the need for mental and behavioral health services continues to increase. Psychologists play a critical role in addressing these needs by treating the mental and behavioral health problems of older adults, particularly those living in underserved communities. During this difficult economic period these services are more critical than ever. According to a recent Census Bureau report, an astonishing 15.1 percent of American adults over the age of 65 are living in poverty (2012). The shortage of psychologists specializing in treating these underserved older adults needs to be addressed.
Critical Need for More Geropsychologists
Geropsychology is a field within psychology devoted to the study of aging and the provision of clinical services for older adults. As researchers, geropsychologists seek to expand knowledge of the normal aging process and design and test psychological interventions that address problems that commonly arise as people age. As health care practitioners, geropsychologists help older persons and their families overcome problems, enhance well-being, and achieve maximum potential during later life (APA, 2005).
The Institute of Medicine (IOM) and the Substance Abuse and Mental Health Services Administration (SAMHSA) report that there is an insufficient supply of trained professionals available to provide mental and behavioral health services to older adults. There are few opportunities available for formal geropsychology training at the graduate level, with only 10-15 programs offering a specialized geropsychology track (IOM, 2012). This shortage will become more dire as the aging population grows and the demand for specialized mental and behavioral health services increases (IOM, 2012; SAMHSA, 2007).
Data indicate that although only 4.2 percent of practicing psychologists identify geropsychology as their primary focus of work, 39 percent of all psychologists report delivering services to adults over the age of 65 each week (APA, 2008). The number of adults age 65 and older is projected to soar to 72.1 million by 2030 — up from 40.3 million in 2010 (IOM, 2012). Without additional specialized educational and training opportunities, psychologists will be unable to meet the increasing demand for mental and behavioral health services as our nation’s population ages (SAMHSA, 2007).
Mental and Behavioral Health Needs and Preferences of Older Americans
Recent data indicate that an estimated 20.4 percent of adults aged 65 and older met criteria for a mental disorder, including dementia during the previous 12 months (Karel, Gatz & Smyer, 2012). More than 50 percent of residents have some form of cognitive impairment, and many nursing home patients have personality disorders exacerbated by chronic health problems (Gabrel, 2007).
Increasing diversity in the older population will affect the provision of mental health/substance use services, requiring training in the provision of culturally competent care in the coming decades (APA, 2009). Psychologists have been at the forefront of research and development of interventions and assessment tools to address the special needs of diverse elders.
Researchers confirm that older adults with evidence of mental disorder are less likely than younger and middle aged adults to receive mental health services and that, when they do, they are less likely to receive care from a mental health specialist (Karel, Gatz & Smyer, 2012).
Because of their coexisting physical conditions, older adults are significantly more likely to seek and accept services in primary care versus specialty mental health care settings (IOM, 2012).
Older Americans underutilize mental health services for a variety of reasons, including: inadequate insurance coverage; a shortage of trained geriatric mental health providers; lack of coordination among primary care, mental health and aging service providers; stigma surrounding mental health and its treatment; denial of problems; and access barriers such as transportation (Bartels et al., 2004).
Older adults often prefer psychotherapy to psychiatric medications (Koh et al., 2010; Areán et al., 2002). However, psychological interventions are often not offered as an alternative.
Anxiety, Depression and Suicide
Mental disorders, such as anxiety and depression, adversely affect one’s physical health and ability to function, especially in older adulthood. For example, untreated depression in an older person with heart disease can negatively affect the outcome of the heart disease (APA, 2005). Conversely, older adults with medical conditions such as heart disease have higher rates of depression than those who are medically well.
15-20 percent of older adults in the United States have experienced depression (Geriatric Mental Health Foundation, 2008). Approximately 11 percent of older adults have anxiety disorders (AOA, 2001). Even mild depression lowers immunity and may compromise a person’s ability to fight infections and cancers (APA, 2005).
Depression is a major risk factor for suicide. In 2006, 14.22 of every 100,000 people age 65 and over died by suicide, higher than the rate of 11.16 per 100,000 in the general population. Non-Hispanic white men age 85 and over are at the greatest risk for suicide, with a rate of 49.8 suicide deaths per 100,000 (CDC, 2006).
Tragically, many of these suicides may have been prevented, as many older adults who die by suicide reached out for help; 20 percent see a doctor the day they die, 40 percent the week they die, and 70 percent the month they die. Yet depression is frequently missed by physicians because older adults are more likely to seek treatment for other physical ailments than they are to seek treatment for depression (NAMI, 2009).
For some older adults, the development of a disabling illness, loss of a spouse or loved one, retirement, moving out of the family home or other stressful event may bring about the onset of a depressive episode (NAMI, 2009).
Symptoms of depression and anxiety in older Americans are often overlooked and untreated because they can coincide with other late life problems (APA, 2005).
Psychologists use psychological interventions, including various psychotherapies and supportive counseling, to treat mental health disorders and help older adults cope with late life stressors. These interventions have been shown to be effective either alone or in combination with psychiatric medications (APA, 2005). Recent research has demonstrated that psychotherapy can be effective for people diagnosed with late-life depression who are at high risk for poor response to antidepressant medication (Areán, Raue, Mackin et al., 2010).
Alzheimer's Disease and Dementia
Dementia is an umbrella term describing a variety of diseases and conditions characterized by decline in memory, negative changes in behavior, and inability to think clearly. In Alzheimer’s disease, these cognitive changes eventually impair an individual’s ability to carry out basic bodily functions (e.g., walking and swallowing) (Alzheimer’s Association, 2012).
Current estimates suggest that 1 in 8 persons over 65 has Alzheimer’s disease; a total of approximately 5.4 million older Americans. This number will continue to grow as the proportion of the U.S. population over the age of 65 increases (Alzheimer’s Association, 2012).
People with dementia often suffer from depression, paranoia and anxiety. Psychologists’ skills in differential diagnosis and treatment are helpful in these complex cases. Psychologists also teach behavioral and environmental strategies to caregivers of those with dementia to deal with these common behaviors (APA, 1998). In addition, psychologists help individuals who are in early stages of dementia to build coping strategies and reduce their stress through psychotherapy and psychoeducational support groups. Memory training strategies often help to optimize remaining cognitive abilities (APA, 2005).
Psychologists also assess a person’s capacity to make health care or legal decisions. They have been at the forefront in developing instruments used to assess capacities in older adults (APA, 2008).
Early diagnosis of Alzheimer’s and effective treatment of the problematic behaviors that often accompany dementia are becoming increasingly possible due to the sensitive diagnostic tools and behavioral and environmental interventions developed by psychologists (APA, 2003). A recent study (Barnes, et al., 2011) notes that up to half of Alzheimer’s cases worldwide are attributable to seven potentially modifiable risk factors — such as diabetes, midlife hypertension, midlife obesity, smoking, depression, cognitive inactivity and physical inactivity. It is estimated that a 10-25 percent reduction in all seven risk factors could potentially prevent as many as 1.1-3 million Alzheimer’ disease cases worldwide.
Incontinence has significant implications for the independence of older adults. It is the second most common reason for families to admit their elder relative to a nursing home and is associated with an increased risk of depression (SAMHSA, 2007). Psychologists use behavioral training treatments, such as biofeedback and bladder training to reduce incontinence. These treatments have proven to be more effective than drug therapy (Burgio, 1998).
Insomnia is prevalent among older adults; 30-60 percent of all older persons have one or more sleep complaints such as difficulty falling and staying asleep, early morning awakenings, excessive daytime sleepiness and daytime fatigue (McCurry, 2007). Psychologists have developed effective non-pharmacological treatments for insomnia, including cognitive-behavioral techniques and sleep hygiene instruction. The availability of these non-pharmacological treatments is particularly important for older adults who are often on multiple medications for management of chronic conditions and are more prone to certain adverse effects of psychiatric medications than their younger counterparts (APA, 2011).
In 2010, at least 5.6 to 8 million older adults had one or more mental health/substance use conditions. A recent study found that illicit drug use nearly doubled among people age 50-59 between 2002 and 2007, increasing from 5.1 percent in 2002 to 9.4 percent in 2007 (IOM, 2012).
The number of older adults in need of substance abuse treatment is estimated to increase from 1.7 million in 2000 and 2001 to 4.4 million in 2020 (Gfroerer et al., 2003).
Psychologists are trained to identify underlying causes and can provide evidence-based treatments to older adults who are engaging in alcohol and substance abuse; e.g. identifying circumstances that trigger these behaviors and teaching adults new methods to cope with high-risk situations.
Approximately 80 percent of older adults have at least one chronic health condition, and approximately 60-65 percent have two or more conditions (Vogeli, et al., 2007; Wolff, Starfield, & Anderson, 2002).
Negative, modifiable behaviors that may contribute to the onset of or exacerbate chronic diseases include poor nutrition, inactivity, smoking and alcohol misuse (Healthy People, 2010).
Psychologists help older adults manage multiple chronic diseases through treatment adherence and behavioral interventions, including physical activity, biofeedback, nutrition and stress reduction techniques (APA, 2005).
Administration on Aging. (2001). Older Adults and Mental Health: Issues and Opportunities. Washington, DC: U.S. Department of Health and Human Services.
Alzheimer's Association. (2012). 2012 Alzheimer's Disease Facts and Figures. Retrieved from: http://www.alz.org/utah/documents/2012_facts_and_figures.pdf
American Bar Association Commission on Law and Aging and American Psychological Association (2008). Assessment of older adults with diminished capacity: A handbook for psychologists. Retrieved from: http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf
American Psychological Association, Government Relations Office. Growing Mental and Behavioral Health Concerns Facing Older Americans. Retrieved from: http://www.apa.org/about/gr/issues/aging/growing-concerns.aspx
American Psychological Association Office on Aging (2005). Psychology and Aging: Addressing Mental Health Needs of Older Adults. Retrieved from: http://www.apa.org/pi/aging/resources/guides/aging.pdf
American Psychological Association, Committee on Aging. (2009). Multicultural Competency in Geropsychology. Retrieved from: http://www.apa.org/pi/aging/programs/pipeline/multicultural-geropsychology.aspx
American Psychological Association. (2008). Survey of Psychology Health Service Providers. Retrieved from: http://www.apa.org/workforce/publications/08-hsp/report.pdf
Areán, P. A., Alvidrez, J., Barrera, A., Robinson, G. S., & Hicks, S. (2002). Would older medical patients use psychological services? The Gerontologist, 42, 392-398.
Areán, P.A., Raue, P., Mackin, R.S., Kanellopoulos, D., McCulloch, C. & Alexopoulos, G. (2010). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. American Journal of Psychiatry, 167, 1391–1398.
Barnes, D.E. & Yaffe, K. (2011). The projected effect of risk factor reduction on Alzheimer's Disease prevalence. Lancet Neurology, 10, 819-828.
Bartels, S.J., Blow, F.C., Brockmann, L.M., & Van Citters, A.D. (2005). Substance abuse and mental health care among older Americans: The state of the knowledge and future directions. Rockville, MD: WESTAT.
Burgio K.L., Locher, J.L., Goode, P.S., et al. (1998). Behavioral vs Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial. Journal of the American Medical Association. 280, 1995–2000.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2006) Web-based Injury Statistics Query and Reporting System (WISQARS) Retrieved from: http://www.cdc.gov/ncipc/wisqars.
Center for Substance Abuse Treatment (1998). Treatment improvement protocol (TIP) #26. Substance abuse among older adults. Rockville, MD: US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration.
Gabrel, C. & Jones, A. (2000) The National Nursing Home Survey: 1997 Summary. National Center for Health Statistics. Vital Health Statistics, 13, 147.
Gfroerer, J., Penne, M., Pemberton, M., Folsom, R. (2003). Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort, Drug and Alcohol Dependence, 69 (2), 127-135.
Healthy People 2010. (2007). Midcourse Review. Retrieved from: http://www.healthypeople.gov/data/midcourse/html/execsummary/introduction.htm
Houser, A., W. Fox-Grage, & Gibson, M.J. (2006). Across the States: Profiles of Long-Term Care and Independent Living. Washington, DC: AARP Public Policy Institute.
Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Retrieved from: http://www.iom.edu/Reports/2012/The-Mental-Health-and-Substance-Use-Workforce-for-Older-Adults.aspx
Karel, M. J., Gatz, M., Smyer, M. (2012). Aging and mental health in the decade ahead: What psychologists need to know. American Psychologist. Vol. 67 (184-198).
Koh, S., Blank, K., Cohen, C. I., Cohen, G., Faison, W., Kennedy, G., et al. (2010). Public's view of mental health services for the elderly: responses to dear Abby. Psychiatric Services, 61(11), 1146-1149.
McCurry, S. M., Logsdon, R. G., Teri, L., & Vitiello, M. V. (2007). Evidence-based Psychological Treatments for Insomnia in Older Adults. Psychology and Aging, 22(1), 18-27.
Mickus, M., Colenda, C. C., & Hogan, A. J. (2000). Knowledge of mental health benefits and preferences for type of mental health providers among the general public. Psychiatric Services, 51, 199-202.
National Alliance on Mental Illness (2009). Depression in Older Persons: Fact Sheet. Retrieved from: http://www.nami.org/Template.cfm?Section=Depression&Template=/ContentManagement/ContentDisplay.cfm&ContentID=88876
National Center for Health Statistics. (2007) Health, United States, 2007. Hyattsville, MD: U.S. Government Printing Office.
National Institute of Mental Health. (2007). Older Adults: Depression and Suicide Facts. Retrieved from: http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact-sheet/index.shtml
Substance Abuse and Mental Health Services Administration. (2007) An Action Plan for Behavioral Health Workforce Development. Retrieved from: http://www.samhsa.gov/Workforce/Annapolis/WorkforceActionPlan.pdf
Qualls, S. H., Segal, D. L, Norman, S., Niederehe, G., & Gallagher-Thompson, D. (2002). Psychologists in practice with older adults: Current patterns, sources of training, and need for continuing education. Professional Psychology: Research and Practice, 33(5), 5435-5442.
Speer, D. C., & Schneider, M. G. (2003). Mental health needs of older adults and primary care: Opportunities for interdisciplinary geriatric team practice. Clinical Psychology: Science and Practice, 10(1).
U.S. Census Bureau. (2012). The Research Supplemental Poverty Measure: 2011. Retrieved from: http://www.census.gov/newsroom/releases/archives/poverty/cb12-215.html
Vogeli, C., Shields, A. E., Lee, T. A., Gibson, T. B., Marder, W. D., Weiss, K. B., et al. (2007). Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine, 22(Suppl 3), 391-395.
For More Information
Contact Alexandra Ginsberg, (202) 336-6062.
Education Directorate Government Relations Office.
This fact sheet was prepared in collaboration with Deborah DiGilio, MPH, director, APA Office on Aging.