have been similar warnings about serious workforce shortages, insufficient workforce diversity, and basic lack of competence and core knowledge in key areas (Hogan, 2003; Hoge et al., 2007; IOM, 2006; Jeste et al., 1999). In health care delivery overall, there is widespread concern about shortages of primary care providers, lack of coordination among health care providers, fragmentation of services, high cost, patient safety, and conflicting information technology systems.1

The convergence of the above issues presents unique challenges for the workforce in geriatric MH/SU care delivery. U.S. health care has always emphasized physical health over mental health (IOM, 2006). Despite some change in societal attitudes, the stigma associated with mental health and substance use conditions is persistent. Today’s health care delivery system and financing arrangements both reflect these realities. For example, until recent legislation mandating parity in some (but not all) health insurance plans, coverage of MH/SU conditions has been strictly limited. The carve-out of MH/SU coverage and service delivery into separate systems is still commonplace.

As Chapter 2 reports, a substantial proportion of older adults have symptoms that warrant the attention of a provider skilled in geriatric MH/SU problems. Yet, only a minority of affected individuals receive specialty care, and the primary care they receive for MH/SU conditions is often inadequate despite the existence of evidence-based screening and treatment models (Bruce et al., 2005; Unützer et al., 2002). Moreover, a growing body of research suggests that inattention to older adults’ mental health and substance use conditions is associated with higher costs and poorer health outcomes, particularly for individuals with multiple comorbidities (Counsell et al., 2007; Katon et al., 2005; Unützer et al., 1997). Available evidence, for example, indicates that older adults with untreated depression are less likely to complete prescription regimens for diabetes, hypertension, and coronary heart disease; more likely to be readmitted after a hospitalization for a medical problem; and more likely to have poor health outcomes after a cardiovascular event, compared to similar patients without mental health problems (Ciechanowski et al., 2000; Garner, 2010; Gehi et al., 2005; Gilmer et al., 2007; Jiang et al., 2001; Krousel-Wood et al., 2010; Lin et al., 2004; Williams et al., 2004).

The barriers to growing and strengthening the geriatric MH/SU workforce are fundamental and entrenched in the systems and programs of numerous public and private entities—including multiple U.S. Department of Health and Human Services (HHS) and other federal agencies, professional organizations, medical and professional training institutions, credentialing and accreditation organizations, licensing bodies, service

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1 See Chapter 1, Box 1-3, for background on the parity legislation.



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