Barriers to Mental Health Care for Older Adults
In their 2012 report, Ageing in the Twenty-First Century: A Celebration and A Challenge, the United Nations Population Fund reports that in 2012 there were over 809 million adults sixty years of age and over in the world - by 2050 the projection is over two billion. Twenty percent of adults fifty-five years of age and older experience some type of mental disorder that is not related to normal aging, and older adults have the highest suicide rate of any age group. Older adults aged eighty-five and over have the highest suicide rate of all (World Health Organization, 2003).
However, of all the older adults who admit to having a mental health problem, less than half receive any treatment for it (American Association for Geriatric Psychiatry 2004). A study of Medicare Current Beneficiary Survey (MCBS) data from 1992-1998 for 20,966 individuals aged sixty-five and older revealed that older adults over the age of seventy-four, people of color, and individuals on Medicare without any supplemental insurance were all less likely to receive treatment even if diagnosed, and if treated, members of these groups were less likely to undergo psychotherapy as a part of their treatment (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003). These alarming statistics reveal three different categories of barriers that prevent older adults from receiving proper mental health care.
Lack of Information
One of the first barriers to mental health care for older adults is a general lack of information. Older adults have less knowledge about mental health and available mental health services than any other population (Yang & Jackson, 1998, in Karlin & Duffy, 2004). Many people, including older adults, have stereotypes that portray gradual mental health decline as a normal part of aging; however, this is contrary to the realities of normal aging, which includes stable cognition, ability to handle changes, and productive involvement with life (U.S. Department of Health and Department of Health and Human Services, 1999).
Many older adults present somatic symptoms when their problem actually originates from a mental health issue (U.S. Department of Health and Department of Health and Human Services, 1999), which probably stems from a lack of education about mental health and may result in a misdiagnosis. Lack of proper education about mental health can also result in denial of a mental health problem by older adults and a fear of being stigmatized (American Association for Geriatric Psychiatry, 2004). Sadly, our entire medical health care system is lacking in knowledge about older adult mental health care and there is a shortage of professionals trained in geropsychology (Halpain, Harris, McClure, & Jeste, 1999, in Karlin & Duffy, 2004).
A further complication to geropsychology is that research on the efficacy of various mental health treatments for older adults have not been undertaken with any significant population (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003, Halpain, Harris, McClure, & Jeste, 1999; in Karlin, 2004).
Unfortunately, such a community lack of information also results in poor inter-agency communication with mental health care and aging networks not properly communicating with each other (American Association for Geriatric Psychiatry, 2004). The solution to this lack of information is threefold: community mental health education, increasing interest in geropsychology among students in mental health care programs, and promotion of communication and cooperation between local mental health care professionals, primary physicians, and community senior centers.
The second barrier to older adults receiving proper mental health care revolves around primary physicians and the finding that because older adults may view a psychological problem as a medical condition, those in need of mental health care tend to go to their primary physician, who often does not give the patient a mental health referral (Karlin & Duffy, 2004; Alvidrez & Areá, 2002, in Crystal et al., 2003). In fact, over half of older adults receiving mental health care are only treated by their primary physician (American Association for Geriatric Psychiatry, 2004). This can actually result in a barrier to proper mental health care due to physician under detection of mental health problems (Gatz & Smyer, 1992, in Karlin & Duffy, 2004) and low referral rates for psychotherapy(Alvidrez & Areá, 2002, in Karlin & Duffy, 2004).
Although some physicians may have a concern about possible side effects and hesitate to prescribe psychopharmacologics in older adults that have medical comorbidities (Crystal et al., 2003), over reliance on pharmacotherapy by the medical community is also a barrier to older adults entering the mental health system (Kisely, Linden, Bellantuono, Simon, & Jones, 2000, in Karlin & Duffy, 2004).
There is a shortage of professionals trained in geropsychology (Halpain, Harris, McClure, & Jeste, 1999, in Karlin & Duffy, 2004), and primary physicians are just not trained as mental health specialists, which is why it is important for them to get past the stigma towards older adult mental health that many professionals have (Gaitz, 1974; Lasoski, 1986, in Karlin & Duffy, 2004) and give their older adult patients proper mental health referrals when needed.
Sadly, a 1994 study found that twenty percent of older adults that committed suicide had visited their primary care physician the same day, and forty percent had visited their physician within one week of the suicide (Conwell, 1994, in American Association for Geriatric Psychiatry, 2004). The solution to these physician related barriers is better education of primary care physicians regarding older adults and mental health.
Patient Costs and Regulatory Barriers
The third hurdle that older adults face in obtaining mental health care is the cost of such care and related regulatory barriers, primarily regarding Medicare. Most older adults have Medicare as their primary medical coverage; however, Medicare requires patients to pay 50% of costs for outpatient mental health treatment, as opposed to the 20% co-payment for most other types of service (American Association for Geriatric Psychiatry, 2004; Crystal et al., 2003). Until recently, Medicare did not cover prescription costs, which was also a significant barrier to older adults in need of pharmacotherapy, and even now, this coverage is only available at an additional cost to the insured and has wide coverage gaps.
It is clear that legislation restricting Medicare reimbursement for mental health services is also a barrier (Sherman, 1996, in Karlin & Duffy, 2004). Normally, indigent older adults are eligible for both Medicare and Medicaid, with the latter paying co-payments not covered by Medicare. However, in recent years, several states have enacted legislation that prevents such crossover payments for mental health services (Nelson, 2002, in Karlin & Duffy, 2004).
Another regulatory barrier is caused by Medicare policies that take treatment decisions out of the hands of mental health care professionals. Local medical review policies (LMRPs) by Medicare carriers that administer claims for outpatient mental health severely restrict what mental health care services are considered medically necessary. Many LMRPs also preclude patients with dementia from receiving psychological services (Karlin & Duffy, 2004), even though the 1991 NIH Consensus Development Conference found that psychotherapy is effective in older adults (National Institutes of Health, 1991).
A related obstacle to older adults receiving psychotherapy is the criteria by which the federal government rates patient care. The federal government uses the Minimum Data Set (MDS) to access the level of care provided to patients in skilled care facilities; however, the quality indicator for the treatment of depression only considers pharmacotherapy a valid treatment. A nursing facility that treated depressed older adults with psychotherapy but not pharmacotherapy would be given a deficient mark for this category (Karlin & Duffy, 2004).
Finally, sometimes erroneous reports create barriers to proper mental health care. In 2001, the Department of Health and Human Service’s Office of the Inspector General released a report concluding that twenty-seven percent of psychiatric services provided to nursing home residents were medically unnecessary, and implied that it is inappropriate to provide cognitively impaired nursing home residents with psychological treatment(in Karlin & Duffy, 2004). The solutions to these barriers are legislative changes and unbiased geropsychological studies.
- The State of Mental Health and Aging in America
Centers for Disease Control and Prevention and National Association of Chronic Disease Directors
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American Association for Geriatric Psychiatry. (2004). Geriatrics and Mental Health – The Facts. Retrieved January 6, 2007, from http://www.aagponline.org/prof/facts_mh.asp.
Crystal, S., Sambamoorthi, U., Walkup, J., & Akincigil, A. (2003). Diagnosis and Treatment of Depression in the Elderly Medicare Population: Predictors, Disparities, and Trends. Journal of the American Geriatrics Society, 51(12). , 1718-1728. Retrieved January 4, 2007, from http://www.medscape.com/viewarticle/465926_1 .
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U.S. Department of Health and Department of Health and Human Services (1999). Chapter 5: Older Adults and Mental Health. In Mental Health: A Report of the Surgeon General. Rockville, MD: Author. Retrieved January 20, 2007, from http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter5 .ref_end