CONTRARY to conventional wisdom, an increase in age can lead to an increase in happiness. In fact, older adults tend to be more satisfied with their lives than their younger peers. But, for those who need it, limited supply of and access to proper geriatric psychiatric treatment leave many older adults' mental health issues under-diagnosed and thus under-treated.
One in four adults ages 65 and older experiences a mental health problem such as depression, anxiety, schizophrenia or dementia, according to the American Psychological Association. And people 85 and older have the highest suicide rate of any age group, especially among older white males who have a suicide rate almost six times that of the general population, according to the National Council on Aging.
The issue of access to mental health care treatment will be further compounded as baby boomers – who carry a higher predisposition to suicide than earlier generations – enter the older adult stage of life. The number of Americans between the ages of 65 and older is projected to double from 46 million to more than 98 million by 2060, according to the American Psychological Association.
But there's a positive side to this ledger.
More health systems across the country are merging mental health care into primary care visits, which older people are more likely to take advantage of, says Dr. Yeates Conwell, director of the geriatric psychiatry program at the University of Rochester.
"Older people ... are not going to go to a mental health center or a mental health provider, but they will more likely accept treatment from their primary care practitioner," Conwell says.
Yet access to proper mental health care for older adults is hindered by modern culture perpetuating the stigmas and misconceptions of ageism and mental health issues; social isolation; high health care costs; and a dwindling supply of geriatric caregivers for America's growing older population.
"The way we treat and take care of people, especially older people, with mental health illnesses is certainly an embarrassment and a shame to society," says Dr. Dilip Jeste, director of the Stein Institute for Research on Aging at University of California–San Diego School of Medicine. "This is one of the most disenfranchised segments of our society."
Addressing the Stigmas of Ageism and Mental Health
Modern culture in America values the new and, in the process, pushes the old aside.
"Ours is a culture that values innovation, which is new knowledge, and devalues wisdom, which is old knowledge or eternal knowledge – knowledge that doesn't change every five years when a new iPhone comes out," says Dr. Renee Garfinkel, a clinical psychologist, author and radio host.
"But something's lost and something's gained in every choice that society makes," Garfinkel adds. "When you're in a society where speed is highly valued, then an old person will not be."
By adapting this mindset, experts say society could be contributing to social isolation and misconceptions surrounding older adults' mental health.
"When older people incorporate the view that they are 'over the hill,' that they are a burden on their families or on their communities, then that's a very dangerous situation," Conwell says, as social isolation has been proven to be as bad for one's health as smoking or lack of exercise.
The stigma of ageism includes negative attitudes, stereotypes and behaviors directed toward older adults based solely on their perceived age. In other words, as people get older, others assume that they have or are increasingly susceptible to mental or physical impairments that make them no longer able to contribute in a way they once were, decreasing their value to the community.
"People with mental illnesses in general get really poor care. There is a considerable amount of stigma against mental illness, and when you talk about aging, there is considerable stigma against aging," Jeste says. "So older people with mental illness have this double whammy: They are stigmatized because of mental illness and stigmatized because they're older."
Further, mental health services may be underutilized by older patients as they may be in denial, may not have adequate insurance coverage, or their other physical chronic conditions may take precedence during a primary care visit, leaving their mental health unchecked.
"I think that time is an issue for practitioners," says Eric Weakly, chief of state and community programs for the western branch of Substance Abuse and Mental Health Services Administration, a division of the Department of Health and Human Services.
"If you're coming and you only have maybe 15 minutes, and you have a person who has multiple chronic conditions – they may be presented with cardiac conditions or diabetes or other things – of the list of conditions, depression, anxiety or another mental illness may not be first on the list when they're doing their screens," Weakly, a social worker, continues.
And, while the number of older adults with mental health disorders is expected to nearly double by 2030, the number of geriatric psychiatrists and psychologists is projected to continue its decline, resulting in less than one geriatric specialist per 6,000 patients with mental health and substance use disorders, according to a 2013 Dartmouth University study.
More than 20 percent of adults aged 60 and over suffer from a mental or neurological disorder, and the most common neuropsychiatric disorders in this age group are dementia and depression, according to the World Health Organization.
Dementia – including Alzheimer's disease, its most common form – affects about 5 percent of individuals between 71 and 79 and 37 percent of the population above the age of 90, according to the American Psychological Association.
But, as Garfinkel explains, growing older doesn't mean you will suffer from a mental health issue. Rather, a longer lifespan exposes a person more, both in terms of mental and physical conditions, which may affect a person's overall psyche.
"The longer you live, the more chance there is for illness to target you, and depression is a risk factor for people who have chronic illness, especially when it's chronic pain," Garfinkel says. "Pain and depression are very highly associated, and a lot of the disorders that strike more often in older age – but not exclusively in old age – are painful."
While depression is not a consequence of getting older, the misconception that it is – either due to bereavement over lost loved ones or the physical pains tied to aging – leads to underdiagnosis and undertreatment by health care professionals and older adults themselves who may not recognize the associated physical symptoms.
A combination of the individual and the people around him or her making incorrect assumptions about depression as a normal part of aging further complicates diagnoses, Conwell says.
"Older people tend in general to be more satisfied with their lives than middle-aged people, and have lower rates of syndromal depression, even though depressive symptoms may be present. But when they are, clinical depression is a syndrome that's made up of a bunch of different symptoms – sadness is only one of them," Conwell continues.
Senior patients may not bring up emotional symptoms, though, opting instead to describe physical ones such as loss of energy, poor sleeping habits, loss of appetite and trouble concentrating, Conwell says, all of which are common with other chronic medical conditions in later life.
Yet mental health correlates with physical health, according to the World Health Organization.
"Older adults with physical health conditions such as heart disease have higher rates of depression than those who are medically well," the organization reported in April 2016. "Conversely, untreated depression in an older person with heart disease can negatively affect the outcome of the physical disease."
Noticing the Spectrum of Mental Health – and Opportunities – for Older Adults
A 2016 study evaluating successful aging from ages 21 to 100 showed that mental health improved with increased age, contrary to the perceived stigma of ageism.
"What we found was that with age the physical health declined, as expected, the cognitive function declines in later life, but the mental health improved with aging in the sense that people seem to get happier, more satisfied, less depressed, less stressed out, in later life than when they were younger," Jeste, co-senior author of the study, says.
"Even people with mental illnesses can do better in later life if society helps them," Jeste says. "The problem is not so much biology; the problem is more what we provide as a society."
As a whole, the 65 and older age group tends to be happier than their younger peers, with reportedly fewer mental health disorders except for dementia as they age.
Like all generations, older adults experience positive mental health when they perceive that they have social support and that they add value to their communities, says Helen Kivnick, a professor of social work at the University of Minnesota.
Yet, she continues, there are fewer social supports and opportunities available for this older generation than for any other stage of the life cycle.
"We would never think about trying to grow a society of healthy kids without families or schools or playgrounds or friendship groups or things like that," Kivnick says. "It shouldn't really surprise us that older people show the ill effects of the absence of these supports, and the supports that we provide we think of as remedial supports rather than ordinary supports for psychosocial health."
Community and family support decline later in life, and loneliness is one of the biggest concerns for older people.
"People get old, and they get isolated, and depending on their social network or their history going into aging – they may have always been a very solo person to begin with – they may want to have control over who they interact with, who they don't interact with," says Dr. Brenda Reiss-Brennan, head of the mental health integration program at Intermountain Healthcare. "So you really have to understand what is their baseline, and where are they now, and what would be acceptable to them to have social contact because social contact is the key to aging well."
But living alone does not mean that a person of any age is lonely, says Dr. John Cacioppo, a professor of psychology at the University of Chicago.
Every day, 10,000 Americans turn 65 years of age or older, Cacioppo says, so it should be no surprise that more are living alone as getting older increases the likelihood that one spouse will pass away before the other. As of 2015, there were nearly 16 million adults ages 60 and above living alone in the U.S., according to the Administration for Community Living's AGing Integrated Database.
"When it's perceived isolation instead of objective isolation, that's called loneliness," says Cacioppo, who is also the director of the university's Center for Cognitive and Social Neuroscience. Perceived isolation accounts for a 26 percent increase in mortality through biological and behavioral processes.
Living alone could lead to autonomy or independence with the right social support system. Maybe you're ready to form new relationships in new groups apart from the family, neighbors or community you spent years growing up with, or dependency forces you into assisted living as isolation is not going to work, Cacioppo says. On the other hand, it could lead an individual to feel uprooted.
"It isn't about objective isolation, moving or not, it's about the psychological impact of that to the individual," Cacioppo says. "One of the worst things you can do is give up all meaning for an older retired adult."
Trying to Fix a Broken System
The costs of health care – especially mental health care – prevent people from all age groups from receiving the treatment they need when they need it.
For older adults, though, the uncertainty of finances to cover health care costs is an enormous stressor, Garfinkel says.
"It is for younger people, but the older you get the fewer options for maneuvering and figuring out your way around it that you have," she says.
In 2016, Congress passed the $6.3 billion 21st Century Cures Act, which included the first major mental health care and substance-abuse legislation to be passed in 20 years. While the mental health portion of the bill did not include much extra funding compared to existing levels, it laid the groundwork to address mental health and requires health insurance companies to cover more mental health treatments.
Still, Jeste says, private insurance companies have found loopholes to avoid covering mental illness, making it less affordable even for patients that have Medicaid or Medicare insurance. Because of this restrictive coverage, physicians may not prescribe a patient the psychotherapy they need because it does not come with the same reimbursement as prescription drugs.
"It becomes a vicious circle," Jeste says. People who need mental health care don't receive it, their condition gets worse, and, as they get older, their access to care declines further as there aren't enough physicians in the geriatric field to provide that care.
"One problem with the health care system is that it is split, and it is very disorganized," Jeste says. "If you provided a unified, integrative, qualitative care, again the prognosis would improve a lot."
Some primary care health systems are attempting to tackle the stigma of mental health by integrating mental health care with physical checkups.
Intermountain Healthcare, with hospitals and clinics throughout Utah and southeast Idaho, is trying to normalize team-based primary care in which a primary care physician has a team of experts to call upon to check on a patient depending on both physical and mental screenings during a regular doctor's appointment.
Integrating the two establishes the connection between physical and mental health, says Dr. Brenda Reiss-Brennan, head of the health system's mental health integration program.
"People like to go to where they are comfortable, and they're comfortable in primary care," Reiss-Brennan says. "Mental health is normalized as a routine part of care, so the staff's more comfortable and confident in dealing with mental health."
Doing so has saved each patient $115 a year, Reiss-Brennan says, from more efficient use of specialists, earlier detection and treatment, and follow-up care plans to more efficiently use all available resources.
And the federal government, under the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration, is working to bring mental health care information into the primary care setting, says Weakly of the Substance Abuse and Mental Health Services Administration.
"We know that most older adults are going to go to primary care physicians first," Weakly says, so fusing behavioral health into primary care will get necessary information to physicians.
Practitioners need to also look at care in different ways, Weakly says, such as going to where people are instead of expecting them to come into the office for therapy or treatment.
"As people in their 50s and 60s are more open about talking about their depression or their bipolar disorder, their schizophrenia, I think things are beginning to change," Weakly says. "People didn't talk about cancer 50 years ago. I think maybe we're getting to a place where people are more comfortable talking about their mental health diagnosis."
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