“Understanding Mental Health and Aging”

  Statement Presented by

Gregory A. Hinrichsen, Ph.D.

Director of Psychology Training, The Zucker Hillside Hospital and Chair,
American Psychological Association Committee on Aging

On Behalf of The American Psychological Association

At the

Congressional Briefing on Older Adults and Mental Health

May 25, 2005

Most people routinely underestimate how well most older Americans contend with the challenges of the later years.  Many think of older Americans as likely to be depressed, demented, and “abandoned” by their families. Sixty percent of older Americans themselves believe that depression is a normal part of aging.  Yet 50 years of well designed studies show that most older Americans are reasonably happy, engaged in activities that are meaningful to them, have good relationships with their adult children, and receive help from family members when they are ill.  Tom Brokow calls older adults whose lives were forged in the Great Depression and World War II “The greatest generation.”  In fact, research indicates that this generation of older Americans may be more emotionally hearty and better able to handle life’s vicissitudes than later generations.  Seventy-five million baby-boomers will soon be entering older adulthood.  Some believe that as a group, babyboomers may be in greater need of mental health services than the current cohort of aged.  Because baby-boomers grew up in a more psychologically minded-era, they will be more likely to access mental health services than the current group of older adults for whom mental health problems were greatly stigmatized. 

A minority of older Americans have mental health problems.  What are the chief mental health problems of older Americans?  Like younger Americans, depressive disorders and anxiety disorders are the most common problems. About 20% of older Americans have mental health problems that include depression, anxiety, sleep problems, and other difficulties. Older Americans are much more likely than younger persons to have cognitive deficits, including dementia.  Older people with mild cognitive deficits have losses of certain mental abilities yet are usually able to function pretty well.  Dementia, however, is a progressive and much more severe loss of mental abilities than mild cognitive deficits.  Persons with dementia have problems remembering, finding familiar places, handling day-to-day affairs, and many other difficulties.  Alzheimer’s disease is the most common type of dementia.  About 6% of people 65 years and older have dementia.  Probably 30% of people over age 85 have dementia.  Older people with dementia often suffer from more than a loss of mental abilities: about 70% of them also have co-existing problems like depression, anxiety, behavioral disturbance, sleep problems, and psychotic symptoms (e.g., seeing or hearing things that don’t exist, believing things that are not true).

When I entered the field of aging in the 1970’s, it was an open question about whether older people with mental disorders could improve with existing treatments.  A lot has happened since then.  Psychotherapies for mental health problems have become much more sophisticated, as have psychiatric medications to treat mental health problems. Research studies – an admirable number of which have been funded by the National Institute of Mental Health – have demonstrated that older people can be successfully treated with psychotherapy and psychiatric medications.  For example, most older people with a serious depression – what we call a major depression – show significant improvements in their symptoms when treated with psychiatric medication, psychotherapy, or a combination.  However, the treatment of depression in older people is more challenging than in younger people.  Older people frequently have medical problems that may make prescribing psychiatric medication more complicated.  Older people treated for depression are more prone than younger people to continue to have a low level of depressive symptoms after initial treatment.  The treatment of older persons with dementia who also have depression, anxiety, psychosis, and other problems is a major challenge for mental health care professionals.  Clinical researchers are trying to find ways to adapt existing psychotherapies for older people with cognitive problems to add to evidence-based practices and to prescribe psychiatric medications in ways that maximize their use.

Two-thirds of older Americans with mental health problems do not receive treatment despite the fact that most older people see a medical doctor at least once a year.  This is notable, since older people with medical problems are much more likely to be depressed.  Yet only a small fraction of primary care doctors who see depressed older adults actually diagnose or treat these disorders.  Most older people who are treated for depression by their primary care doctors do not receive adequate treatment – that is, treatment that reflects evidence-based and best practices.  Only a small proportion of older adults who are actually diagnosed by their primary care physicians with serious depression, and who are referred to a mental health specialist, actually go to the specialist.  This generation of older people may have attitudes about the mental health system and the stigma associated with mental disorders that make them reluctant to go to a mental health specialist.  And economically disadvantaged, racial/ethnic minority, and rural-residing older adults are even less likely to receive care.

There is a growing consensus that mental health care providers need to deliver services in primary care medical settings.  Depression and other mental health problems are fairly common among patients in these settings; younger, as well as older, people are much more likely to access care that is on the same site as primary care doctors; and on-site mental health specialists can provide care that is evidence-based and reflects best practices.  The provision of mental health services to older adults where they live or congregate also increases the likelihood that those in need of mental health services will actually access them. 

Let me illustrate some of these issues by briefly describing a patient of mine.  Betty is a 72-year-old woman whom I recently treated at The Zucker Hillside Hospital, which is part of the larger North Shore – Long Island Jewish Health System in New York City and suburban Long Island .  Betty saw a newspaper article about a depression treatment study that a colleague and I are conducting and decided to take part in it.

Betty is caring for her 82-year-old husband who has advanced Parkinson’s disease.  He is not only having problems with walking but also has depressive symptoms and some cognitive deficits.  Betty herself had symptoms of depression for about a year and then became seriously depressed about two months before she came to see me.  She also had problems with sleeping and concentration, and felt increasingly hopeless and anxious, and – of most concern to her – problems caring for her husband.  As she explained, “I feel like it’s overwhelming to even wash my face in the morning.” 

As part of our study, Betty was treated with a time-limited, evidence-based treatment for major depression, called Interpersonal Psychotherapy.  Interpersonal psychotherapy is one of several psychotherapies (others include problem-solving therapy and cognitive behavioral therapy) that have been tested in clinical studies and found to be effective in the treatment of depression.  These psychotherapies are evidence-based and reflect best practice – that is, there is solid evidence that they work.  And there are an increasing number of studies that have shown that most psychotherapies that work with younger people are useful for older people. 

The goal of Interpersonal Psychotherapy is to significantly reduce depressive symptoms and empower depressed patients to improve the life issues that likely prompted the depression.  The focus of my psychotherapy with Betty was how she could get additional help and support from her children and others in the care of her husband, deal with the sorrow of seeing her husband become increasingly debilitated, and contend with the day-to-day issues that came up in the caring for her husband.  The therapy built on Betty’s long history of successfully dealing with a variety of life problems.

Betty did great.  After 16 weeks of psychotherapy, she had a significant reduction in depressive symptoms and – in our language as mental health care professionals – no longer met criteria for a major depression. 

The purpose of the research study in which Betty took part is to examine brain changes in older adults with major depression as symptoms of depression improve with psychotherapy.  At the end of the study, it will be interesting to see changes in Betty’s brain as her depressive symptoms improved during psychotherapy.

What are larger issues that we can learn from the particulars of the treatment of Betty’s depression? 

1. Overall rates of major depression are relatively low among older people.  However, 15-20% of older adults have symptoms of depression or anxiety.  Further, persons with health problems are much more likely to have diagnosable mental health problems.  Five to ten percent of older people visiting their primary care doctor have major depression; 10% of older people in the hospital have major depression; and up to 20% of older people in long term care settings have major depression. 
   
   

2. Family members providing ongoing care to an older relative are at risk for the development of a mental health problem.  Some have estimated that up to 50% of family members providing care to a chronically ill relative will develop a diagnosable mental health problem, including depression and anxiety.  
   
   
   
3. Major depression is a terrible disorder.  It affects how people feel, think, and is associated with physical symptoms like sleep and appetite changes.  A large study conducted several years ago found that major depression impairs people’s ability to function as much as heart disease and cancer.  Major depression is the chief risk factor for suicide.  Older adults – particularly white older men – have the highest suicide rate of any age group.  When older people attempt suicide they are much more likely to die than younger people.  Persons with major depression are more likely to develop physical health problems.  Persons with physical health problems who are depressed are slower to heal from physical health problems.
   
   
4. Although the combination of psychiatric medication and psychotherapy usually works best in treating depression, each have been shown to be effective in reducing depressive symptoms. 
   
   
5. In our research, PET scans of the brain are done before psychotherapy, during psychotherapy, and after psychotherapy.  PET scans show how different parts of the brain are active or inactive.  Major depression results in changes in activity in the brain.  There is growing evidence that antidepressant medication and psychotherapy “normalize” the brain.  There have been remarkable advances in the last 20 years in our ability to understand how the brain influences behavior and how behavior influences the brain.

What legislative efforts can improve the mental health and well-being of older Americans?

1. Enactment of the Positive Aging Act of 2005 will increase coordination of mental and physical health care for older adults through outreach and provision of services offered in places frequented by older adults.
   
   
2. Support of mental health parity legislation.  Currently, outpatient mental health care services are only reimbursed by Medicare at 50%, unlike medical care services which are reimbursed at 80%.  This issue is especially important for older Americans in nursing homes.  A 50% reimbursement rate for mental health services discourages mental health care professionals from providing such services.   
   
   
3. Increase funding through the Older Americans Act, the Community Mental Health Services Block Grant, and the Social Services Block Grant to expand the availability of mental health and supportive services, including caregiver support, respite care, in-home services and transportation.   
   
   
4. Enhance opportunities for training of health professionals to address the growing number of older adults in need of mental health and behavioral health services.  A recently published study of ours, for example, found that most doctoral psychology students are interested in providing psychological services to older adults.  
   
   
5. Expand basic and applied behavioral research and research training at the National Institute of Mental Health and National Institute on Aging.  Also increase funding for the widespread dissemination of evidence-based and emerging best practices for the mental health treatment of older Americans. This is an exciting era in our understanding and treatment of mental health problems in older Americans.  We should be proud of the accomplishments that have been made, honor past legislative efforts that have been critical to those accomplishments, and support additional efforts aimed at addressing late life mental health problems so as to make the lives of the “greatest generation” and the generations that follow more productive and meaningful. 

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