Daniel D. Sewell, MD
Director, Senior Behavioral Health, UC San Diego Medical Center
President, American Association for Geriatric Psychiatry
(This blog post originally appeared on CareForYourMind.org, a resource created by the Depression and Bipolar Support Alliance (DBSA) and Families for Depression Awareness (FFDA) to help society engage in critical discussions and decisions about mental health.)
For most individuals in the U.S., accessing mental health care is a struggle, but older adults may have it worst of all. Due to stigma, misinformation, and false beliefs about aging, they frequently go without adequate care for depression and other psychiatric illnesses and psychological problems. Too often, doctors offer prescription drugs as a cure-all solution, and fail to address the overall mental health and well-being of the older patient.
The truth is, addressing mental health issues in older populations requires paying more attention, not less. In aging adults, depressive symptoms can point to a physical illness, while physical pain or other physical complaints can often be a sign of mental health issues.
The good news is, when accurately diagnosed, mental health issues are just as treatable in older populations as in younger, but it takes commitment and understanding. In order to help aging Americans get healthier and happier, the system needs to properly address the physical and mental needs of these patients.
What gets in the way of patient-centered care?
Research shows that older adults are often less comfortable seeking care from a mental health professional than their younger counterparts. Due to historical shame and ignorance surrounding mental illnesses and psychological problems, stigma tends to be more powerful among those who came of age before the 1960s.
Depression is also experienced, witnessed, and treated differently in older adults. In this population, depression symptoms can present as physical complaints, irritability, and/or cognitive impairment rather than overt signs of sadness such as crying. Alternatively, psychiatric symptoms can often point to a physical ailment that’s been overlooked. Depression can also be an early sign of dementia.
Additionally, medical illnesses are too often misdiagnosed or wrongfully labeled as purely psychiatric illnesses. To test this theory, we did a six-month chart review in our geriatric psychiatric inpatient unit and discovered that 34% of patients referred to our unit had a previously unrecognized or documented but inadequately treated medical illness—and that illness was likely the source of the psychiatric symptoms. Based on that data, one out of three older patients may actually need medical care versus behavioral health care.
Insurance issues
Insurance companies also get in the way of good care. To cite one shocking example, a nurse employed by a continuing care community in my area was checking in on a patient. When she arrived, she saw the resident on the balcony, with one leg over the railing, clearly about to jump. Luckily, the nurse was able to pull the patient back. I was immediately contacted. When I tried to get pre-authorization for inpatient care from the patient’s insurance company, they told me she didn’t meet the criteria for care because she hadn’t actually jumped.
In addition, doctor’s appointments have been cut so short that there’s no time to address all of a patient’s needs or issues. Say a patient mentions insomnia in the last 30 seconds of a 15-minute visit; the physician doesn’t have time to further explore the issue, so the physician writes a prescription for a sleep medication. Meanwhile, the insomnia could be pointing to a host of physical or mental ailments, which if diagnosed and treated properly would resolve the insomnia and eliminate the need for a medication for insomnia and thereby protect the patient from the many potential risks as well as costs associated with a medication for insomnia. Without the physician spending more time or truly paying attention to what the patient is saying, what’s the chance the patient will actually get well?
To be fair, sometimes patient expectations are also part of the challenge of providing optimal medical and psychiatric care. We live in a world where many individuals have come to expect unrealistically quick results and where a person may feel disappointed if a doctor does not provide a medication to resolve the issue which prompted the appointment with the doctor.
PCPs are the gateway to better patient outcomes
The above issues point to a serious gap between mental and physical health care in older adults. Because many providers aren’t connecting the dots, many patients end up misdiagnosed or overlooked.
The answer is integrated care. For older adults in particular, receiving mental health help at their primary care provider’s office makes the process easier. This kind of care lessens stigma, makes transportation easier, and helps them feel more comfortable. The whole system works better when primary care providers and mental health providers can work side by side and collaborate on providing care that addresses patient needs and preferences.
Unfortunately, this kind of collaborative care isn’t widely available for Medicare patients — yet — but there are efforts underway to push our system in this direction. Currently, there are few incentives in place for physician practices, but the more we can offer financial rewards for integrated care, the more quickly we’ll be able to help the millions of older adults in need.
Older adults deserve psychological wellness
Older adults have the same end goal as everyone else: to feel as healthy and happy as they can. They want affordable treatments that have minimal side effects. They want the freedom to work with their doctors to choose treatments that are right for them. Our current system makes these goals too hard to attain.
Moving forward, we need to recognize the unique needs of our older population and do a better job of addressing them. While they may have different concerns, issues, and attitudes, it’s important to remember that they have as much potential for psychological well-being as younger patients. They deserve care that helps them be as happy and high-functioning as possible.