Improving Behavioral Health Care for Older Americans Now, Not Later.

President Joe Biden has addressed the national mental health crisis several times, urging the nation to achieve parity between physical and mental health care. The White House published an associated brief?outlining strategies to tackle the crisis, including strengthening system capacity, increasing access, and identifying priority populations. This national attention has marked a phenomenal opportunity to address the mental health needs of all Americans, which include the mental health needs of older adults.

Behavioral health needs of older adults are often not identified or addressed, despite approximately 20 percent of older adults meeting criteria for some type of mental health diagnosis.?Baby boomers have higher rates of behavioral disorders than earlier cohorts of older adults. Additionally,?substance use among older adults is an emerging public health issue, with?high-risk alcohol use and other drug use growing among this cohort. Mental health comorbidities within older populations shorten their lifespans and have high costs to families, health systems, and society.

Scope Of Geriatric Behavioral Health Burden

Aging is associated with unique challenges that can negatively impact mental health,?including loss of social support, increased illness burden, and functional decline. For many reasons, including ageism, mental health conditions such as depression among seniors often go?underdiagnosed and undertreated. Many older adults with mental illnesses also have chronic physical illnesses. The reverse is also true: living with chronic physical illnesses makes seniors more likely to develop a mental health condition, which can also be life-shortening.

Depression is the most prevalent mental health disorder experienced by seniors; in fact,?seniors ages 85 and older are at the highest risk for suicide of any age group.?Depression can cause similar symptoms as dementia and Alzheimer’s and can be an early warning sign of dementia. Although the rate of older adults with depressive symptoms tends to increase with age,?depression is not a normal part of growing older,?and is a treatable condition.

A?Lancet?commission on depression?discussed an association between loneliness and the development of depressive symptoms, especially later in life and within the context of COVID-19. Moreover, the experience of caring for an older adult with a behavioral health condition is typically challenging and can be an isolating experience that places caregivers at risk of becoming depressed or anxious themselves.

Key Challenges

Number of Geriatric Professionals in Behavioral Health

Overall, the US has a substantial workforce gap in meeting the needs of people with behavioral health conditions.?This is especially true for behavioral health professionals?who have special training and expertise in geriatrics. For example,?less than 1,300 geriatric psychiatrists are active in the United States with severely disproportionate allocation.?More than half of geriatric psychiatrists live in one of seven states (California, Florida, Massachusetts, New Jersey, New York, Pennsylvania, and Texas). Additionally,?many behavioral health practitioners do not accept fee-for-service Medicare, the insurance model used by most older adults.

Barriers To Access

Due to lingering stigma and scarcity of services in the US, mental health care access for the general population remains difficult and is even more constrained for the older population. Additionally, older adults with evidence of?mental disorders?are less likely than younger adults to?be diagnosed?or?receive mental health services. When they do receive mental health services, they are less likely to receive care from a mental health specialist.?Only 20–25 percent of older adults with mental disorders receive services from mental health professionals.

Low utilization of mental health services reflects access?problems stemming from social factors such as stigma, ageism, and ignorance about mental illness and the effectiveness of treatment.?Structural barriers?to access include but are not limited to severe workforce and service shortages, issues of affordability, restricted access to medications, shortage of services in the home and community settings, lack of transportation, and lack of culturally competent care. While the rise of telemedicine during COVID-19 has helped circumvent transportation issues, older Americans can have difficulty affording, accessing, and using devices.

Strategies For Overcoming Barriers

Integration

Integrated care services are crucial to meet the needs of the growing numbers of individuals with multiple complex chronic conditions in need of comprehensive care in a cost-effective manner. Mental health service delivery should be integrated into health and aging services, including primary care, serious illness care, home health care, adult medical daycare, adult homes, assisted living, nursing homes, behavioral health inpatient hospital program, community-based outpatient facilities, senior centers, and so forth.

Community-based care delivery models are a growing approach to delivering coordinated, comprehensive care to the older population that often struggles with complex needs. Community integration investment and successes can provide supports that enable older adults to age in place, as a significant proportion of the population desire.

Strong integration and delivery of mental health services enable older adults with dementia, major depression, anxiety disorders, or long-term psychiatric disabilities to remain in or return to the community after getting the help they need.

Accountability And Payment Models

Achieving integrated care requires a payment model that incentivizes and encourages flexibility, quality, and innovation. Leaders in health and aging policy advocate for policy changes such?as bundled, capitated, and other value-based payments to promote the holistic and attentive delivery of care. However, it is essential that in applying these payment mechanisms, models should apply accountability mechanisms linked to patient outcomes that are shared both across behavioral health and general medical providers.

Technology

Telemedicine and technological procedures have important roles in the care of older adults as this population and its demand for behavioral health care grow. Despite access limitations and some age-related health challenges such as vision or hearing problems, cognitive decline, and decreased motor skills that may make telemedicine difficult for some,?older adults want to follow technological developments and can successfully adapt to telemedicine.

Moreover, age-related challenges have not been shown to block older adults from successfully using telemedicine. Provider best practices have been developed and can include practice runs with specified platforms, collaborating with patient family/caregiver, using assisted technologies, and so forth. Providers can set up older adults with training and tools necessary for successful telemedicine adoption, and?older adults demonstrated high stakeholder satisfaction with telemedicine.

The Answer Is Now

Faced with the task of improving behavioral health care for older Americans, the question we should ask remains, “If not now, when?” In 2019, 54.1 million people in the United States were ages 65 and older, with the?number projected to reach 89 million by 2050. With this drastic demographic shift, we cannot afford to wait.

In 1994, the?Gerontologist?published “Mental Health Care for Older Adults in the Year 2020: A Dangerous and Avoided Topic,”?which accurately predicted that health care structures would be ill-equipped to effectively meet the behavioral health needs of older adults today. It failed to factor in a pandemic or the role that technology would play in clinical medicine but aimed to bring attention to this looming structural shortcoming. The reality today is that solutions for meeting the needs of this population depend on integrated health services success.

Creative evidence-based solutions are developed to confront drastic changes in our health care system, population demographics, and needs. With COVID-19 bringing unprecedented attention to the nation’s mental health and well-being, there is finally newfound hope that the mental health needs of older adults will be more fully and effectively addressed.