The Mental Health and Substance Use Workforce for Older Adults In Whose Hands? (2012) / Chapter Skim
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2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions
2 Assessing the Service Needs of Older Adults with Mental Health and Substance Use Conditions
Pages 39-158
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From page 39... ...
By 2030, expected growth in the older population will increase the number of older people with MH/SU con ditions by 80 percent. Many older adults with MH/SU conditions also have physical health conditions and cognitive, functional, and sensory impairments that can complicate the detection, diagnosis, and treatment of their MH/SU conditions and create difficult caregiving situations for their families and professional and other service providers.
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From page 40... ...
Later sections describe the coexisting physical health conditions and cognitive and functional impairments that shape the MH/SU service needs of older adults; review the impact of MH/SU conditions; and discuss the available data on use of MH/SU services by older adults and factors that could affect their future MH/SU service needs. The last section summarizes the chapter findings about the current and future MH/SU service needs of the older population.
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From page 41... ...
In addition, at least four types of age-related factors can cause, complicate, and exacerbate MH/SU conditions. The four factors are physiological effects of normal aging; changes in life circumstances that frequently occur in old age; coexisting physical health conditions that are common in older adults; and cognitive, functional, and sensory impairments that affect substantial numbers of older adults, especially those age 75 and older.
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From page 42... ...
Major Depressive Disorder and Major Depressive Episode (described below) are often referred to as major depression.
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. Bipolar I and II disorders are usually re ferred to as bipolar disorder.
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10. Posttraumatic Stress Disorder (PTSD)
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Schizophrenia is a DSM-IV-TR mental disorder that lasts for at least 6 months, including at least 1 month during which the person has two or more of the following: positive symptoms (delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior) , and/or negative symptoms (restrictions in the range and intensity of emotional expression, the fluency and productivity of thought and speech, and the initiation of goal directed behavior)
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From page 46... ...
12. Alcohol Dependence and Alcohol Abuse are DSM-IV-TR mental disorders that meet the requirements for substance dependence and abuse defined with respect to alcohol.
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From page 47... ...
Depressive Symptoms is a term to describe symptoms, such as depressed mood and feelings of worthlessness and guilt, that do not meet the criteria for a diagnosis of a DSM-IV-TR depressive disorder, usually because of insufficient duration, number, or se verity. Other terms for such symptoms are subsyndromal depres sion, subthreshold depression, subclinical depression, and minor depression (Blazer, 2003; Lavretsky and Kumar, 2002; Lyness et al., 2009)
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From page 48... ...
22. Behavioral and Psychiatric Symptoms Associated with Dementia is a term to describe noncognitive symptoms of diseases and conditions that cause dementia.
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From page 49... ...
. DSM-IV-TR defines diagnostic criteria for several dementia related mental disorders, and coding specifications for behavioral and psychiatric symptoms can be added to these disorders, but behavioral and psychiatric symptoms associated with dementia are not classified as DSM-IV-TR mental disorders.
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From page 50... ...
3. Acute and chronic physical health conditions that are common in older adults and medications to treat the conditions can cause and exacerbate DSM-IV-TR mental disorders and other MH/SU con ditions and worsen their impact on the person (Blow and Barry, 2002; Jeste et al., 2005; Schultz, 2011)
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From page 51... ...
. The complex interactions among MH/SU conditions and these agerelated factors, especially coexisting physical health conditions and cognitive, functional, and sensory impairments, have been described by many geriatric mental health professionals and researchers as a key or defining characteristic of the field (Alexopoulos, 2005; Blazer et al., 2004; Borson et al., 2001; Bruce et al., 1994; Bryant et al., 2009; Cohen, 1996; Flint, 2002; Katz, 1996; Knight, 2004; Lyness et al., 2006; Reynolds et al., 2002)
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From page 52... ...
Because of their coexisting physical health conditions, older adults with MH/SU conditions are frequently seen in medical care settings, such as primary care offices, hospitals, and emergency departments. Likewise, because of their coexisting physical health conditions and cognitive and functional impairments, older adults with MH/SU conditions may be receiving nursing and nonmedical personal care services at home or in a residential care setting, such as a nursing home or assisted living facility.
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From page 53... ...
people living in housing units, including houses, apartments, mobile homes, and single rooms occupied as separate living quarters, and (2) people living in group quarters, including nursing homes, prisons and jails, psychiatric hospitals, residential treatment centers, and homeless shelters (Census Bureau, 2010a)
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From page 54... ...
. Available information about the proportions of assisted living, senior housing, and public housing facility residents that have MH/SU conditions and implications for their service needs and related workforce requirements are discussed later in the chapter.
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From page 55... ...
. The samples included people living in the community and excluded people living in prisons, jails, nursing homes, and long-term med ical or dependent care facilities, and military personnel living on a military base.
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From page 56... ...
. The sample includes residents of households and non institutional group quarters, such as shelters, halfway houses, and rooming houses, and civilians living on military bases, and excludes homeless people who do not use shelters, military personnel on active duty, and residents of prisons, jails, nursing homes, mental institutions, and long-term hospitals.
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From page 57... ...
Among those people, 800,000 to 900,000 people had two or more conditions, and 200,000 to 300,000 people had three or more conditions. The conditions with the highest prevalence are depressive disorders, including major depressive episode and dysthymic disorder.
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From page 58... ...
Mental health conditions Depressive disorders 3.0-4.5 1.2-1.8 Major depressive episode(s) 3.0-4.3 1.2-1.7 Dysthymic disorder 0.6-1.6 0.2-0.6 Panic disorder 0.8-1.1 0.3-0.4 c-0.3 d-0.1 Agoraphobia without panic Social phobia 0.9-2.6 0.4-1.0 Generalized anxiety disorder 1.1-2.1 0.4-0.8 Posttraumatic stress disorder 0.6-2.6 0.2-1.0 (PTSD)
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From page 59... ...
Rates for the tenth condi tion, behavioral and psychiatric symptoms associated with dementia, are not included in Table 2-2 because the only available population-based data for this condition come from a survey that included both communityliving older adults and nursing home residents, whereas the data for the other nine conditions come from studies that include only community
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From page 60... ...
Prevalence rates for behavioral and psychiatric symp toms associated with dementia are discussed later in this section. The middle column of Table 2-2 shows the prevalence rate or range of rates for each of the nine conditions.
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From page 61... ...
. High levels of coexisting physical health conditions, especially heart disease and ulcers, are also common in such people (Pietrzak et al., 2012; Schnurr et al., 2000)
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Mental health conditions c-0.2 d-0.1 Bipolar disorder Schizophrenia 0.2-0.8 0.1-0.3 Obsessive-compulsive 0.8 0.3 disorder Depressive symptoms 1.1-11.1 0.4-4.3 Anxiety symptoms 4.3 1.7 Suicidal ideation 0.5-1.7 0.2-0.7 c d Suicide plans and attempts Substance use conditions At-risk drinking 5.2 2.0 At-risk drug use 0.9 0.4 a Prevalence rate is the rate or range of rates from the cited sources. b The number of people was calculated by multiplying the percentages in the middle column by 38.8 million.
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From page 63... ...
Some researchers and clinicians question whether the prevalence of mental disorders in general, and the three disorders in particular, is identified accurately by the structured interviews used in the large-scale, population-based surveys conducted to date. For bipolar disorder, schizophrenia, and OCD, they question whether the surveys have found and interviewed representative samples of older adults with the disorders and whether valid prevalence rates can be generated from the relatively small numbers of older survey respondents that have the disorders (Alegria et al., 2007; Cohen et al., 2000; Depp and Jeste, 2004; Gum et al., 2009; Nelson and Rice, 1997; Palmer et al., 1999; Wu et al., 2006)
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From page 64... ...
In addition to prevalence rates for the three DSM-IV-TR mental disorders, Table 2-2 shows prevalence rates for six other MH/SU condi tions. The 5.2 percent rate for at-risk drinking represents the proportion of community-living adults age 65 and older with subsyndromal alcohol dependence, defined as self-reported alcohol use that meets one or two of the seven DSM-IV-TR criteria for alcohol dependence, but not the three or more criteria required for a DSM-IV-TR diagnosis of the disorder (Blazer and Wu, 2011)
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From page 65... ...
The range of prevalence rates for depressive symptoms, 1.1 to 11.1 percent, comes from four population-based studies intended to measure depressive symptoms that did not meet the DSM-IV-TR diagnostic criteria for a depressive disorder. One study found that 11 percent of a national random sample of 137,000 community-living Medicare beneficiaries age 65 and older reported feeling "depressed or sad much of the time over the previous year" (Harris and Cooper, 2006)
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From page 66... ...
ADAMS is the only U.S. study conducted to date that has measured these behavioral and psychiatric symptoms in a nationally representative sample of community-living older adults and nursing home residents, but
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From page 67... ...
b The behavioral and psychiatric symptoms measured in the Aging, Demographics and Memory Study come from the 10-item version of the Neuropsychiatric Inventory (Cummings et al., 1994)
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From page 68... ...
The seven conditions include two DSM-IV-TR mental disorders (adjustment disorder and personality disorders) and five other MH/SU conditions (hoarding, severe 1 U.S Census data show there were 25.7 million people age 71 and older in 2010, and AD AMS data indicate that 13.9 percent of people in that age group (about 3.6 million people)
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From page 69... ...
The available data on three other MH/SU conditions -- hoarding, severe domestic squalor, and severe self-neglect -- come from case reports and administrative records of public health departments and aging and adult protective services agencies. For example: • Massachusetts public health officers who responded to a survey about formal complaints of hoarding received by their depart ments identified 471 complaints received from 1992 to 1997, sug
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From page 70... ...
. Prevalence of MH/SU Conditions in Older Adults Living in Group Quarters Settings With the exception of the figures presented earlier on behavioral and psychiatric symptoms associated with dementia, the figures presented thus far in this section have been for community-living older adults.
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From page 71... ...
TABLE 2-4 Prevalence and Estimated Number of Nursing Home Residents Age 65 and Older with Selected Mental Health Conditions, 2009 Prevalence Rate Number of Residents Condition (%) with the Condition Mental health conditions Depression 49.6 590,834 Anxiety disorders 16.1 192,071 Bipolar disorder 2.8 33,416 Schizophrenia 3.6 42,521 Summary figures One or more conditions 56.8 675,622 SOURCE: Shaping Long-Term Care in America Project and Brown University, data provided to the IOM committee, November 2011.
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From page 72... ...
. The proportion of nursing home residents with mental health conditions will probably continue to change as nursing homes increasingly admit people for short-term, postacute care as opposed to long-term personal care and supervision.
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From page 73... ...
New nursing home admissions with mental health conditions are more likely than other new admissions to stay in the nursing home for at least 90 days (Grabowski et al., 2009)
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From page 74... ...
. Data from the Iowa prison system for the years 1996-2001 show that 23 percent of inmates age 55 and older had mental health conditions and 71 percent had a history of substance dependence or abuse, primarily involving alcohol (Arndt et al., 2002)
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From page 75... ...
Some have both a mental health condition, such as a depressive disorder, and a substance use condition, such as alcohol dependence. In addition, some older adults have more than one mental health condition, for example, a depressive disorder and generalized anxiety disorder, and some have more than one substance use condition, for example, alcohol dependence and nonmedical use of prescription drugs.
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From page 76... ...
. • In a small research sample of 18 adults age 60 and older who had a hoarding condition, 28 percent also had major depressive disorder; 22 percent also had dysthymia; 16 percent also had OCD; 5 percent also had social phobia; and 5 percent also had general anxiety dis order (Ayers et al., 2010)
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From page 77... ...
As shown in Table 2-5, an estimated 2.2 million to 2.9 million communityliving older adults and nursing home residents have behavioral and psy chiatric symptoms associated with dementia. Combining the number of community-living older adults with depressive disorders from Table 2-1 (1.2 million to 1.8 million people)
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From page 78... ...
With the exception of nursing home residents, more prevalence and
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From page 79... ...
Severe forms of other mental disorders, such as major depression, are sometimes also included, but substance use conditions are not included. In 1993, people with serious mental illness were defined in federal regulations as people "age 18 and older, who currently or at any time in the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that has resulted in functional impairment that substantially interferes with or limits one or more major life activities" (SAMHSA, 1993)
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From page 80... ...
At a minimum, combining the 535,000 communityliving older adults identified as having SMI based on the SAMHSA meth odology and the 76,000 nursing home residents with bipolar disorder and schizophrenia indicates that at least 611,000 older adults (about 1.5 percent of the older population)
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From page 81... ...
As shown in Table 2-6, 5.4 percent of older Medicare and Medicaid beneficiaries had SMI in 2005, including 1.1 percent who had schizophre nia and paranoid disorders, 1.1 percent who had bipolar disorder, and 3.2 percent who had major depression. Among those with SMI, the data indicate that
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From page 82... ...
TABLE 2-6 82 Number and Proportion of Massachusetts Medicare and Medicaid Beneficiaries Age 65 and Older with Serious Mental Illness, Other Mental Illness, and No Mental Illness by Age, Gender, Place of Residence, Insurance, and Coexisting Dementia, 2005, N = 679,182a Mental Health Status Serious Mental Illness (SMI) Conditions Serious Mental Schizophrenia and Bipolar Major Other Mental No Mental Characteristics Illness (SMI)
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From page 83... ...
E Clark, University of Massachusetts Medical School, unpublished data provided to the IOM committee, November 2011.
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From page 84... ...
Residents of assisted living, senior housing, and public housing facilities 5. Older adults who are dually eligible for Medicare and Medicaid 6.
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For the 10 MH/SU conditions measured in each of three surveys (the CPES, NESARC 1, and NESARC 2) , prevalence rates were generally higher for the age group 65-74 than the age group 75 and older, although some differences are very small (Center for Multicultural Mental Health Research, 2011)
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From page 86... ...
Prevalence rates for behavioral and psychiatric symptoms associated with dementia are probably higher for the oldest old than for adults ages 65-74 and 75-84. This is because dementia is much more common in adults age 85 and older than in the younger age subgroups (Brookmeyer et al., 1998; Hebert et al., 2003)
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From page 87... ...
. Information about the prevalence of MH/SU conditions in the oldest old is needed to plan for adequate services and workforce competencies to care for this population that also has very high rates of coexisting physical health conditions and cognitive and functional impairments.
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From page 88... ...
. For example, the midpoint of the prevalence rates from the three surveys for depressive disorders is 4.8 percent for older women and 2.6 percent for older men (Center for Multicultural Mental Health Research, 2011)
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From page 89... ...
. All the conditions are DSM-IV-TR mental disorders.
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From page 90... ...
(%) Mental health disorders Depressive 3.8 3.6 6.9 4.0 disorders Major depressive 3.5 3.4 6.1 3.5 episode Dysthymic disorder 1.0 0.7 2.0 0.7 Panic disorder 0.9 0.7 1.8 1.8 Agoraphobia 0.1 0.2 0.3 0.1 without panic Social phobia 1.7 1.7 1.1 1.5 Generalized anxiety 1.5 1.7 1.7 2.5 disorder Posttraumatic stress 1.5 2.3 3.2 1.3 disorder (PTSD)
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From page 91... ...
SOURCE: Center for Multicultural Mental Health Research, 2011. the range of prevalence rates from the three surveys for each disorder and for one or more, two or more, and three or more disorders.
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From page 92... ...
These factors include whether the person was born in the United States or elsewhere, and, if born elsewhere, how old the person was at the time of immigration; how long the person has been in the United States; the person's gender, education, and income; perceived financial strain; life events; and region of the country. The following examples come from studies selected to illustrate the interrelationships among these factors and prevalence rates: • Among older Asian Americans living in the United States, the prevalence of major depression was much higher for Chinese Americans age 65-74 than for Filipino and Vietnamese Americans in that age group.
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From page 93... ...
Residents of Assisted Living, Senior Housing, and Public Housing Facilities Many older adults live in assisted living, senior housing, and public housing facilities. The first National Survey of Residential Care Facilities found that in 2010, there were about 31,100 assisted living and other residential care facilities in the United States (Park-Lee et al., 2011)
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From page 94... ...
One study of 198 residents age 58-104 in 22 randomly selected assisted living facilities in central Mary land used an expert panel to identify those with mental disorders based on resident records and in-person interviews (Rosenblatt et al., 2004)
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From page 95... ...
A third study of 945 residents age 60 and older in six public housing facilities designated specifically for seniors used in-person screening tests and structured interviews to identify residents with mental disorders (Rabins et al., 1996) : • 8 percent were found to have mood disorders, including 5.6 per cent with major depression, 1.7 percent with dysthymia, and 0.4 percent with bipolar disorder; • 4.6 percent were found to have psychotic disorders, including 2.1 percent with schizophrenia;
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From page 96... ...
96 TABLE 2-8 Proportion of Assisted Living and Residential Care Residents with Behavioral Symptoms in the Previous Week, by Mental Health Conditions and Dementia Behavioral Symptoms One or Physically More Physically Nonaggressive Verbal Behavioral Aggressive Resistance Symptoms Symptoms Symptoms Symptoms to Care Condition (%)
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From page 97... ...
With respect to major depression, which was measured in public housing, assisted living and nursing home resi dents and community-living people, the proportion of older adults with the condition is lowest in those living in the community; it is progres sively higher in public housing residents and assisted living residents, and highest in nursing home residents. For alcohol dependence or abuse, which was measured in public housing– and community-living older adults, the proportion of public housing residents with the condition was higher.
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From page 98... ...
First, it is clear that substantial numbers of older adults with these conditions live in assisted living, public housing, and senior housing facilities. Two of the studies described earlier show that 26 to 28 percent of older assisted living residents had mental health conditions.
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From page 99... ...
Research and analyses conducted to date to categorize and identify assisted living and other residential care facilities for the 2010 National Survey of Residential Care Facilities should allow for the identification of these facilities as a distinct type of congregate-living setting in future surveys of MH/SU conditions. Similar research and analyses are needed to allow for the identification of public housing and senior housing facilities as distinct types of congregate-living settings.
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From page 100... ...
The figures include veterans who were living in VA nursing homes and VA domiciliary care facilities, but they do not include veterans who were living in non-VA nursing homes and other facilities, even if the VA was paying for their care in the facility. As shown in the table, 16 percent of older veterans who used VA health care services had a diagnosis of one or more of the MH/SU conditions.
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From page 101... ...
b Number is less than 500. SOURCE: Department of Veterans Affairs, FY 2011 data provided to the IOM committee, March 22, 2012.
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From page 102... ...
They include diagnoses of minor depression, affective personality disorder, and depressive disorders that are either superimposed on another mental disorder that is the person's primary diagnosis or cannot be disaggregated from an underlying physical health or substance use condition. Behavioral and psychiatric symptoms associated with dementia are not included in Table 2-9.
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From page 103... ...
Knowledge about these relationships is an important competency for physicians and other health care and MH/SU professionals who work with older adults because that knowledge may allow them to prevent some conditions or at least to recognize a causal relationship and reduce its negative effects on the person. Often, however, there is no direct causal relationship between a person's mental health or substance use conditions and his or her physical health conditions or cognitive impairment.
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From page 104... ...
Information about their physical health conditions was self-reported. TABLE 2-10 Proportion of Community-Living Primary Care Patients Age 60 and Older with Depressive Disorders and Selected Physical Health Conditions, N = 1,801 Prevalence Rate Physical Health Conditions (%)
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From page 105... ...
of those with major depression also had cognitive impairment. Anxiety disorders and anxiety symptoms also coexist with physical health conditions and cognitive impairment (Palmer et al., 1997; WolitzkyTaylor et al., 2010)
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From page 106... ...
Analysis of service needs and the workforce competencies required to meet those needs must take into account the high rates of coexisting physical health conditions and cognitive impairment in older adults with MH/SU conditions. IMPACT OF MH/SU CONDITIONS MH/SU conditions in older adults are associated with a wide range of negative effects, including emotional distress, functional disability, reduced physical health, increased mortality, suicide, high rates of hos pitalization and nursing home placement, and high costs.
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From page 107... ...
W Li, University of Michigan School of Social Work, Ann Arbor, MI, unpublished data provided to the IOM committee, March 12, 2012.
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From page 108... ...
Many of the available studies are based on crosssectional data and therefore cannot demonstrate a causal relationship between MH/SU conditions and negative effects. In addition, as discussed previously, MH/SU conditions, physical health conditions, and cognitive impairment frequently coexist in older adults, and it is difficult to disentangle the relative contributions of these conditions to the nega tive effects.
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From page 109... ...
Their higher mortality has been attributed to many factors, including poor compliance with prescribed medical treatments for physical health conditions; toxic effects of medications prescribed for their MH/SU condition; negative health behaviors, such as excessive use of alcohol and drugs, smoking, and inactivity; poor-quality medical care; poverty; lack of health insurance; and lack of coordination in the medical and specialty MH/SU systems (Druss and von Esenwein, 2006)
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From page 110... ...
, making mental disorders the eighth most costly condition for adults age 65 and older in the United States in 2009. The MEPS includes community-living people and excludes people living in nursing homes, prisons, or jails.
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From page 111... ...
The large gap between the $17.1 billion figure from MEPS and the $2.4 billion figure based on Medicare reimbursement data reflects differences in the people, conditions, services, and payers included in each figure. • The Medicare reimbursement data pertain to all community-living adults and nursing home residents age 65 and older who were enrolled in fee-for-service Medicare in 2009 but exclude about 9.8 million Medicare beneficiaries (25 percent of all Medicare benefi ciaries age 65 and older)
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From page 112... ...
112 TABLE 2-12 Medicare Reimbursement for Mental Health and Other Substance Use Services for Fee-for-Service Beneficiaries Age 65 and Older, 2009 Medicare Reimbursement ($ Millions) All MH/SU Mental Health Alcohol Use Drug Use MH/SU Service Providers Services Services Only Services Only Services Only All providers 2,440 2,259 108 73 Hospitals 1,558 1,413 85 60 1,267 1,136 75 57 • Community hospitals Inpatient care 935 818 63 53 –Specialty MH/SU unit 694 680 8 5 –General unit 241 138 55 48 Outpatient care 319 306 11 3 –Specialty MH/SU unit 3 3 0 0 –General unit 317 303 11 3
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From page 113... ...
291 278 10 3 • Psychiatric hospitals Inpatient care 214 202 9 3 Outpatient care 77 76 0 0 Nursing homes 174 160 12 2 Home health care 119 117 1 1 Physicians 294 282 7 5 203 200 2 1 • Psychiatrists 90 81 5 4 • Other physicians Psychologists, nurses, social workers, 245 243 1 0 counselors, other nonphysician MH/SU service providers, and other professionals Laboratories 13 9 1 4 Ambulance services 50 46 2 2 SOURCE: Thomson Reuters, 2011.
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From page 114... ...
In 2009, SMHAs across the country operated and/or funded nearly 20,000 public and private mental health organizations, settings, and providers, including 212 state psychiatric hospitals, 70 private psychiatric hospitals, 440 general hospitals with a separate psychiatric unit, 59 nursing homes and intermediate care facilities for mental illness (ICF-MI) , and 18,847 community mental health centers and providers (SAMHSA, 2009)
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From page 115... ...
States' define the eligibility criteria for services operated or funded through their public mental health system, but all states include services for people with SMI, and states generally prioritize services for people with low income and those who are uninsured or have only Medicaid (Garfield, 2011)
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From page 116... ...
The main focus of these organizations and settings is medical and medically related care for physical health conditions. All of these or ganizations and settings provide care for older adults, and most of them provide some MH/SU services for some older adults.
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From page 117... ...
Includes adult correctional facilities, housing organizations, settings that serve homeless people, adult protective service agencies, public health agencies, and organizations and settings funded by the Indian Health Service.
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From page 118... ...
Yet, federal government initiatives that target, for example, organizations, settings, and providers that receive Medicare payments and may include training, credentialing, or other workforce requirements will apply to some but not all organizations, settings, and providers that are part of the state-defined public mental health system or the array of community agencies that are considered by local governments to be providing MH/SU services. Likewise, state government initiatives that target organizations, settings, and providers that comprise the state's public mental health system will apply to some, but not all organizations and settings categorized as providing MH/SU services at the federal or local level.
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From page 119... ...
One study of more than 600 community-living adults age 60 and older who were receiving health-related and social services from a public long-term care agency assessed their attitudes and beliefs about mental health service use and compared the attitudes and beliefs of those who had depression (either a DSM-IV-TR depressive disorder or depressive symptoms) and those who did not (Morrow-Howell et al., 2008)
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From page 120... ...
. Mental disorders have been found to be strongly associated with elevated risk of suicide.
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From page 121... ...
Nevertheless, 31 percent of those age 65-74 and 26 percent of those age 75 and older said they would be embarrassed if their friends knew they were getting professional help for an emotional problem. The 2001 NSDUH found that among community-living older adults with mental health conditions, only 10 percent reported receiving any mental health services (Karlin et al., 2008)
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From page 122... ...
. A recent analysis of the beliefs of white, black, Hispanic/ Latino, and Asian American older adults about the causes of mental health conditions found significant variation among groups that is likely to affect help-seeking behaviors (Jimenez et al., 2012)
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From page 123... ...
In the context of older adults' positive beliefs about the importance of obtaining mental health services and the likely effectiveness of such services, however, these other factors interact with perceived stigma and related attitudes and beliefs to reduce older adults' willingness to use MH/SU services. Professional and other service providers who interact with older adults in specialty MH/SU, general medical, residential, and home- and community-based care settings should be aware of the array of attitudes, beliefs, and other factors that influence older adults' decisions about MH/SU service use and able to identify and implement approaches to reduce such barriers to needed services.
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From page 124... ...
Most of the surveys do not include institutionalized people; thus, they do not include people living in nursing homes. The surveys differ somewhat in the MH/SU conditions and kinds of services they include.
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From page 125... ...
household study used a telephone interview and mailed questionnaire to assess use of mental health treatment in a stratified random sample of 9,585 adults age 18 and older. The study found that adults age 65 and older with mental health conditions were less likely than those age 30-64 with the conditions to receive mental health treat ment (53 versus 60 percent, respectively)
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From page 126... ...
Coexisting physical health conditions in older people with MH/SU conditions mean that they are often receiving care in general medical settings and are, therefore, familiar with and perhaps comfortable in these settings. Simi larly, coexisting physical health conditions and cognitive and functional impairments mean that some older adults with MH/SU conditions are receiving care in general residential and home- and community-based settings.
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From page 127... ...
The researchers hypothesized that the older adults may have needed case management more than younger adults because of their coexisting medical conditions and functional impairments, and that as a service, case management may be more acceptable than the other services to older adults with schizophrenia. Another study conducted in the San Diego county public men tal health system from 2002 to 2006 found that adults age 60 and older were more likely than those under age 60 to enter the system through the Psychiatric Emergency Response Team (PERT)
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From page 128... ...
, but concerns remain about overuse, inappropriate use and negative effects of all these medications, especially in older people who are taking multiple medications for other physical health conditions (McLendon and Shelton, 2012)
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From page 129... ...
The table shows 12-month prevalence rates for 10 DSM-IV-TR mental disorders
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From page 130... ...
(%) Mental health conditions Depressive 10.0 8.8 6.4 3.7 2.1 disorders Major depressive 9.8 8.4 6.4 3.7 2.0 episode Dysthymic 2.9 3.5 2.1 0.9 0.7 disorder Panic disorder 3.3 3.2 2.1 0.5 1.8 Agoraphobia 1.0 1.3 0.8 0.4 0.2 without panic Social phobia 8.2 7.0 5.2 3.6 1.1 Generalized 4.7 4.8 4.2 1.8 1.3 anxiety disorder Posttraumatic 3.4 4.6 3.7 0.8 0.4 stress disorder Substance use conditions a a Alcohol 3.0 1.9 0.7 dependence or abuse a a a Other drug 1.1 0.5 dependence or abuse Summary figures One or more of 20.4 19.8 14.1 8.2 4.8 the disorders Two or more of 9.4 8.4 5.8 2.5 1.8 the disorders Three or 4.7 4.3 3.3 0.8 0.5 more of the disorders a The prevalence rate from the CPES is less than 0.2 percent.
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From page 131... ...
The committee agrees that the prevalence of these conditions will increase in coming decades, but concludes that it is not possible at present to predict the rates or number of older adults who will have the conditions in 2020 or 2030. Table 2-14 shows 12-month prevalence rates for self-reported alcoholrelated and drug-related conditions in community-living adults age 65 and older at 2-year intervals from 2000 and 2010.
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From page 132... ...
(%) Alcohol-related conditions Binge alcohol use in the past montha 6.1 7.5 6.9 7.6 8.2 7.6 Heavy alcohol use in the past monthb 1.5 1.4 1.8 1.6 2.2 1.6 Alcohol dependence/abuse in the past yearc 1.4 1.2 1.4 1.3 1.0 2.0 Drug-related conditions Illicit drug use in the past yeard 0.7 1.3 0.9 1.1 1.4 1.7 e Marijuana use in the past month 0.5 0.3 0.5 0.4 1.0 Nonmedical use of prescription drugs in the 0.6 0.7 0.6 0.6 0.9 0.9 past year f Nonmedical use of prescription pain 0.4 0.4 0.5 0.8 0.4 relievers in the past year e e Drug dependence/abuse in the past yearc 0.1 0.1 0.2 0.1 a Binge alcohol use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other)
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From page 133... ...
• A 2011 report, based on data from the Drug Abuse Warning Net work surveillance system, shows that 61 percent of the 1.1 million emergency department (ED) visits for adverse drug reactions in 2008 involved a person age 65 or older and nearly one-quarter of these ED visits were for adverse reactions to central nervous system drugs, including narcotic and nonnarcotic pain relievers (CBHSQ, 2011a)
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From page 134... ...
In addition to increases in the number of older adults with MH/SU conditions that result from growth in the size of the older population and increases in prevalence rates for particular MH/SU conditions, another factor that will affect the future number of older adults with these condi tions is changes in the age composition of the older population. As noted earlier in this chapter, 54 percent of the 40.3 million adults age 65 and older in 2010 were age 65-74, 32 percent were age 75-84, and 14 percent were age 85 and older (Census Bureau, 2011b)
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From page 135... ...
. Analyses conducted for the committee by the Center for Multicultural Mental Health Research show that the prevalence of DSM-IV-TR mental disorders varies in different racial and ethnic groups.
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The preva lence of diagnosed PTSD is very high in the groups ages 35-44 and 55-64. Prevalence rates for some other conditions, notably diagnosed alcoholrelated and drug-related conditions, are higher in the group age 45-54.
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From page 137... ...
137 ASSESSING THE SERVICE NEEDS TABLE 2-15 Continued Age Group MH/SU Diagnoses 35-44 45-54 55-64 65-74 75+ Other mood 18.0 18.8 16.7 9.7 6.9 spectrum disorders Schizophrenia 1.7 3.1 2.4 1.0 0.5 Bipolar disorder 4.3 4.7 2.5 1.2 0.4 Other psychoses 1.0 1.4 1.1 0.6 0.9 Panic disorder 2.0 1.6 1.1 0.5 0.2 a a a a a Agoraphobia without panic a a Social phobia 0.2 0.2 0.1 Generalized 2.3 2.1 1.8 1.1 0.8 anxiety disorder Posttraumatic 15.0 9.6 16.4 6.7 2.5 stress disorder Substance use diagnoses Alcohol 8.2 12.2 9.7 4.3 1.2 dependence or abuse Other drug 6.0 10.0 5.4 1.1 0.2 dependence or abuse Summary figures One or more of 35.5 37.8 37.5 20.6 12.2 the diagnoses Two or more of 19.3 20.5 18.2 7.4 2.9 the diagnoses Three or more of 8.9 10.1 7.5 2.4 0.7 the diagnoses a Proportion is less than 0.1 percent.
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From page 138... ...
In general, more information is available about the proportion and number of older adults with DSM-IV-TR-defined mental disorders, but the committee did not find data to support estimates of the number or proportion of older adults with two of the DSM-IV-TR mental disorders, and the accuracy of the available data on three other DSM-IV-TR conditions is unclear. For the 5.6 million to 8 million adults age 65 and older with one or more MH/SU conditions, the most prevalent conditions were DSM-IV-TR depressive disorders and behavioral and psychiatric symptoms associated with dementia.
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From page 139... ...
Certainly they create important requirements for workforce competencies, including ability to detect possible MH/SU conditions in older adults with coexisting physi cal health conditions and cognitive and functional impairments; ability to diagnosis the conditions or knowledge about how to refer the person for a diagnostic evaluation; and ability to adapt treatments and ongoing management to accommodate the coexisting conditions. A substantial proportion of older adults with MH/SU conditions live in nursing homes and other congregate-living settings, such as assisted living, senior housing, and public housing facilities.
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From page 140... ...
American Journal of Psychiatry 159(10)
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From page 141... ...
2011. Nursing home ad missions and long-stay conversions among persons with and without serious mental illness.
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From page 142... ...
American Journal of Geriatric Psychiatry 9(3)
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From page 143... ...
Table 1.11A -- illicit drug use in life time, past year, and past month, by detailed age category: Numbers in thousands, 2009 and 2010. http://oas.samhsa.gov/NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.11A (accessed February 22, 2012)
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From page 144... ...
Table 1.6B -- serious mental illness in the past year among persons aged 18 or older, by gender and detailed age category: Percentages, 2009 and 2010. http://www.samhsa.gov/data/NSDUH/2k10MH_Findings/2k10MH_ Dtables/Sect1peMHtabs.htm#Tab1.6B (accessed February 22, 2012)
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From page 145... ...
2003. Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: The Memory and Medical Care Study.
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From page 146... ...
American Journal of Geriatric Psychiatry 4(1)
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From page 147... ...
Depression diagnosis and antidepressant therapy in elderly long-stay nursing home residents, 1999 to 2007. Journal of the American Geriatrics Society 59(4)
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From page 148... ...
2009. Mental illness in nursing homes: Variations across states.
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From page 149... ...
2011. Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents.
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From page 150... ...
American Journal of Geriatric Psychiatry 11(5)
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From page 151... ...
2010. Recent changes in the prevalence of psychiatric disor ders among VA nursing home residents.
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2004. Disruptive behaviors in Veterans Affairs nursing home residents: How different are residents with serious mental illness?
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From page 153... ...
American Journal of Geriatric Psychiatry 15(6)
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From page 154... ...
2012. Physical health conditions associated with posttraumatic stress disorder in U.S.
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From page 155... ...
2005. The association of neuropsychiatric symptoms and envi ronment with quality of life in assisted living residents with dementia.
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From page 156... ...
American Journal of Geriatric Psychiatry 15(1)
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From page 157... ...
2000. Recent care of common mental disorders in the United States: Prevalence and conformance with evidence-based recommendations.
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