I measure every Grief I meet
With narrow, probing, eyes –
I wonder if It weighs like Mine –
Or has an Easier size.
-- Emily Dickinson
Over the last 2 weeks, how often have you felt down, depressed, or hopeless? This is one of the questions used in the PHQ-2, an assessment tool that can help identify someone at risk for serious depression. Screening tools also help identify risk for other behavioral health or substance use disorders. As with all health issues, early detection and treatment leads to better outcomes.
Greater awareness of mental health needs has helped bring more resources to bear to address them. In his 2022 State of the State address, Governor Mike DeWine, in announcing new resources for behavioral health services for children, noted that nearly 60 years ago, President John F. Kennedy, called for community-based mental health care, so that “Many more mentally ill can be helped to remain in their own homes without hardship to themselves or their families.”
We now have a better understanding of mental health and mental health services. Screening tools and new treatments have been developed. Efforts have been made to reduce the stigma associated with seeking help. But we have a long way to go. Especially in addressing the unique needs of older adults.
Myths about aging and mental health
One of the barriers to effective mental health services for older adults is a tendency to consider mental illness as inevitable. As is true at any age, older adults can experience mental illness. But it is not normal or inevitable. Depression or its symptoms, such as irritability or lack of energy may be written off as part of growing older. Lack of sleep, or exercise, can aggravate health problems, including mental health. An individual may be afraid to ask about issues like memory loss, concerned over a diagnosis of dementia. If older adults, their family members or their doctors do not detect a problem or share their concern, it goes untreated. The National Institute on Aging has helpful fact sheet on Five Myths of Aging.
Not just the blues
Anyone, at any age, may experience loss or sadness. We all can have anxious moments, forgetting a name, or hunting for our car keys (or glasses, or mobile phone!). But for one in six older adults, behavioral health problems are significant enough to impact their daily lives. According to SAMHSA, the Substance Abuse and Mental Health Services Administration, up to 4.8 percent of Americans aged 65 and older experience serious mental illness (SMI) that can create significant functional impairment. SMIs, which include schizophrenia, bipolar illness and major depressive disorders, contribute to higher risk for other poor health outcomes and other chronic health conditions. Older adults account for 17.9 percent of suicide deaths. A 2016 Survey of Drug Use determined that approximately 863,000 older adults have a substance use disorder. These are serious health concerns. Most conditions can be addressed; symptoms can be treated or cured. But fewer than one-quarter of older adults seek treatment.
Older adults are 40 percent less likely to seek treatment than younger persons, according to SAMHSA. One reason people do not seek treatment is the stigma associated with mental illness or substance use. It may be seen as a sign of personal failure or moral weakness. Fear or shame may prevent some older adults to share their concerns with family or their health providers. Stigma, combined with symptoms of mental illness, or in combination with other health issues can result in greater social isolation, which further reduces the likelihood the person will seek help.
Lack of resources
Even when older adults seek help, it may be difficult to find. Many communities report a shortage of qualified mental health professionals, and there are even fewer who providers who specialize in treating older adults. Workforce shortages will likely continue to worsen. The population of older adults grew by 33 percent over the past decade and is projected to nearly double by 2060. There simply are not enough professionals entering the field to replace those who will retire in the next decade, let alone enough to meet the needs of a growing population of people aged 65 and older.
In addition to too few providers, there are also too few places to access care. SAHMSA estimates there are 12,750 mental health treatment facilities in the US. Three-quarters of these are community or out-patient sites (as compared to 24-hour inpatient or hospital units). Community Mental Health Centers are not available in all areas, particularly in rural and low-income urban areas. One vulnerability in the system is access to community supports after a patient completes in-patient treatment. There are often lengthy waiting lists for community supports. As a result, a person completing a successful treatment for schizophrenia, substance use or bipolar disorder is unable to access follow-up services that are proven to reduce rehospitalization, emergency room visits, or relapse.
What to do about it
Raising Awareness and Addressing Stigma
Information and education efforts can be powerful tools in raising awareness and reducing the stigma associated with mental illness or substance use disorders. Efforts can also be made to raise awareness among healthcare professionals and other service providers about signs and symptoms of mental illness and treatment.
More awareness of the mental health needs of older adults is also needed. Mental illness and cognitive decline are not inevitable or normal. Still, the treatment of mental illness or substance use disorders can be different for older adults, especially in consideration of changes in metabolism as we age, or the impact of other chronic health issues. Mental health does not end when someone is diagnosed with dementia. Residents in assisted living, skilled nursing facilities or other congregate living settings also need access to quality mental health care.
Addressing resource issues
Public policy, public health and workforce development efforts are needed to ensure that services are available to older adults who need them. To address workforce issues, more emphasis needs to be placed on increasing the number of degreed and licensed professionals in the field, with particular emphasis on those working with older adults. Attention needs to be given as well to the role of non-clinical staff, community health workers and even family members in addressing mental health and substance use. Peer education and chronic disease self-care and management are also powerful tools to engage the patients or clients themselves in their care.
Beyond workforce capacity, effective public policy is necessary to address mental health for older adults. This includes ensuring that payment rates are sufficient to support necessary services. Attention is needed to ensure parity in coverage of mental health services compared to other treatments. Public policy also should consider the unique needs of older adults in addressing substance use, suicide prevention and other health priorities.
There are a variety of resources available to learn more strengthening mental health services for older adults.