Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0129aThe Psychiatrist’s Rolein Linking Community ServicesDeirdre Johnston, Kimberly A. Sherrill and Burton V. ReiflerWake Forest University School of Medicine, Winston-Salem, NC, USAIn addressing the mental health needs of older adults in the USA,psychiatrists are faced with a number of significant challenges.One of them remains sheer demand: the number of patientsneeding services still outstrips the availability of psychiatrists,especially those with specialized geriatric training. A secondchallenge is that of collaborating effectively with the primary caresector who, as will be described in some detail later, providemental health care for the vast majority of the elderly. Third is thechallenge of understanding and working effectively with a widerange of non-physician providers of services to older adults. Theseand other difficulties will likely become more pressing as thedemographic trends towards an older society are accompanied byincreasing financial restrictions.Many psychiatrists are responding to these challenges byenlarging their role from that of generalist clinicians to geriatricspecificeducators, academicians and researchers, as well assources of expertise for innovative community-based programs.We will begin by documenting the need for services, alluded toabove, and follow with examples of how those role changes arebeing manifested in important new programs and initiatives. Weconclude with comments on future directions for the psychiatrist’srole in the process of change, and a discussion of some of thepremises underlying the current system of mental health care forthe elderly.THE NEED FOR MENTAL HEALTH SERVICESAMONG THE COMMUNITY-BASED ELDERLYOne way to estimate the current need for mental health servicesamong the community-dwelling elderly is to take the prevalencerates of mental illness and subtract the portion of those alreadyreceiving services. In terms of prevalence rates, the elderly appearto have rates of mental disorders about the same as those ofyounger adults 1 . One of the more conservative estimatedprevalence rates for lifetime psychiatric disorders, 12.3% 2 ,comes from the Epidemiological Catchment Area (ECA) study,while another recent community-based study documents a higherrate of 31% 1 .Using specific and fairly restrictive criteria, Shapiro et al. 3estimated from ECA data that some 7.8% of those aged 65+need mental health services. If the ECA study results can begeneralized to the population as a whole, and given that the vastmajority (99.6%) of the nation’s 29.8 million adults aged 65+reside in the community rather than in institutional settings (USCensus Bureau statistics, 1987), then some 2.3 million communityresidingelderly may be said to need mental health care.Many of those needing services are not seeing a mental healthprofessional. In Goldstrom et al.’s Bunker Hill study 1 , amongpatients aged 65+ with a psychiatric disorder, only 42% had atleast one visit to a mental health professional, compared to 68%among the 18–44 age group ( p50.01) and 53% among the 44–64age group ( p50.01). Shapiro et al. calculated that 5.7% of thetotal population of elderly need, but are not receiving, mentalhealth services. About one-third of those needing mental healthservices are being seen by the specialty mental health sector,another one-third receive care only from general medical careproviders, and the other one-third receive no care 2 . Recentevidence suggests that considerable barriers still exist in the publicsector that prevent the elderly from receiving specializedpsychiatric care 4 . The elderly have tended to be slow to reportpsychiatric symptoms compared to younger adults 5 .The fact that so many patients with mental health needs arebeing seen by the general medical sector (the ‘‘de facto mentalhealth system’’) 6 is important for several reasons. Numerousstudies document that primary care practitioners overlookpsychiatric disorders in their patients 7,8 , and, even when treatingpatients for mental disorders, tend to do so inadequately 9 . It hasalso been suggested that physicians may misinterpret somaticmarkers of depression as being due to physical illness 10 . In theUSA, an increasing number of older adults are enrolled inmanaged care plans, which usually require that the primary carephysician treat most uncomplicated illnesses, limiting access tospecialist care. Recent evidence suggests significant differences inthe treatment of older people with depression enrolled in healthmaintenance organizations (HMOs) compared with youngerdepressed patients. Older patients received fewer mental healthspecialty visits, fewer prescriptions for SSRI antidepressants, andwere more likely to be prescribed benzodiazepines 11 . As themanaged care model expands nationwide, the evidence remainsthat the depressed elderly are underserved 12 . Thus, there is a greatneed to train primary providers in the detection and treatment ofmental disorders. Also, geriatric patients with mental disordersmake twice as many office visits to their primary care providers asdo those without a mental disorder 1 . If those patients receivedadequate treatment, then according to the so-called ‘‘cost-offset’’hypothesis, the improvement in mental health would result insubstantial decreased utilization of other health care services, thus‘‘offsetting’’ the expense of providing mental health care 13,14 .Investigators estimate that treatment for mental disorders isaccompanied by an overall 20% decrease in the use of generalPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd