Dr. Knight is Assistant Professor of Nursing, Department of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Margaret Knight, PhD, RN, PMHCNS-BC, Assistant Professor of Nursing, University of Massachusetts Lowell, Department of Nursing, 3 Solomont Way, Suite 2, Lowell, MA 01854-5126; e-mail: Margaret_Knight@uml.edu.
By 2030, 70 million adults will be older than 65 and will account for 20% of the U.S. population (Centers for Disease Control and Prevention [CDC] & Merck Company Foundation, 2007). The prevalence of mental health problems in older adults is underestimated, and despite the fact that these problems are not a normal part of the aging process, nearly 20% of the population 55 and older have some form of a mental health problem (U.S. Surgeon General, 1999). Common problems include depression, anxiety, cognitive impairments, and substance abuse. Although significant gains have been made in our understanding of how mental health problems affect older adults, little progress has been made toward improving access to appropriate and available resources to diagnose and manage these problems.
Older adults are a vulnerable population and experience disparate access to mental health care. Research has reported the negative impact of mental health problems on the general health and functional health status of older adults (Menchetti, Cevenini, De Ronchi, Quartesan, & Berardi, 2006; Tsai, Wei, Lin, & Chien, 2005). Greater access to mental health care is critical for community-dwelling older adults in need of these services to maximize quality of life, improve function, and maintain independence.
Several factors contribute to the lack of access to mental health care, including those related to the individual, the provider, and the health care system. These factors were identified by the Institute of Medicine (2002) when describing causes of ethnic and racial disparities in health care, and they are also applicable to the current problem of access to mental health care for older adults.
Factors Related to the Individual
Factors related to the individual can be intrapersonal or interpersonal in nature. Decisions to access mental health care encompass the individual’s knowledge of mental health-related issues; beliefs and values about mental health and treatment; motivation to seek treatment; and mental health-seeking behaviors. A brief discussion of significant factors follows.
Older adults may not seek mental health care because they may lack knowledge of and understanding about the link between physiological and mental health. Somatic presentation of psychological symptoms is not uncommon (Sheehan, Bass, Briggs, & Jacoby, 2003). Symptoms such as fatigue, decreased appetite, and weight loss are commonly associated with physiological health in an individual who has never experienced psychiatric symptoms, despite also being symptoms of mental health problems. Further, the aging process is often attributed as the cause of new symptoms, and individuals neglect to report them to primary care providers (PCPs). For example, depression, the most common mental health problem in older adults, often goes unrecognized by the individual, family, and significant others (Knight & Houseman, 2008). Depression has been linked to increased perception of pain, immobility, and more days spent in bed (Menchetti et al., 2006; Tsai et al., 2005), clearly increasing the risk for poor functional health.
Complex medication regimens are another cause for concern among older adults. Those with complex illnesses may experience multiple medication changes on a frequent basis to manage health problems. Decreased metabolism and excretion, drug interactions, problems with adherence, and mistakes in administration can all lead to abrupt changes in cognitive status or the insidious onset of mental status changes (Chemali, Chahine, & Fricchione, 2009; Mallet, Spinewine, & Huang, 2007). Few older adults question PCPs about the side effects of medication. Psychiatric and cognitive symptoms associated with the initiation of medication may not be reported due to lack of recognition of the relationship between medication use and symptoms. In addition, cognitive decline may not be recognized because the cognitive tasks of older adults may not be demanding (Balsis & Cully, 2008). Cognitive tasks may be performed daily, and few problem-solving skills are associated with repetitive and familiar daily tasks.
Multiple Physiological Health Problems
Although many older adults maintain health well into their 70s and 80s, the risk for the development of health problems increases with age. Health problems may be simple and managed effectively through routine primary care visits. However, complex health problems often lead individuals to multiple providers in multiple locations, often without timely communication among providers. The complex drug regimens that are often associated with complex health problems can lead to mental health symptoms such as confusion or delirium. The fee-for-service option of the Medicare system supports the use of multiple providers, but without case management to oversee the integration of care, providers may unknowingly contribute to anxiety and confusion about treatment and follow-up care.
Follow-up care can be difficult for older adults because of low energy and motivation, difficulty solving day-to-day problems such as obtaining needed medication or arranging transportation, and the need for physical assistance to attend follow-up appointments (Knight & Houseman, 2008). Poor adherence may become both a cause and an effect of mental health problems.
While there is greater recognition about physiological, biochemical, and structural etiologies of mental illness, stigma continues to be a significant negative influence on the decision to seek mental health care. Stigma relates to the experience of being socially rejected, devalued, or discriminated against; it can also include the experience of shame (Lundburg, Hansson, Wentz, & Björkman, 2009). These negative attitudes about oneself or stigmatization by others can lead an individual to deny symptoms or delay important treatment, which can lead to further decline in mental health (CDC, 2010). Older adults may feel embarrassed by mental health symptoms, and individual perceptions of mental health problems may have a negative cultural context, which serves as a barrier to seeking mental health care (Shellman, Mokel, & Wright, 2007).
Compared with younger adults, older adults are more likely to perceive that an individual with psychiatric symptoms can exert more control over the management of those symptoms and should “just get over it”; they are also more likely to be critical of those with psychiatric symptoms (Webb, Jacobs-Lawson, & Waddell, 2009). Older adults grew up in an era when mental health problems were poorly understood by the public and infrequently discussed. Symptoms, therefore, were sometimes perceived as a sign of weakness or as a personal flaw (Mills, Alea, & Cheong, 2004; Shellman et al., 2007). Acknowledging mental health changes and determining the need to seek treatment may not be an option for many older adults.
Individuals with complex health problems visit PCPs and specialists often but may not be fully independent. Many rely on family, friends, and community supports to access health care providers. Initiating mental health care adds additional burden to these supports, and limited access to transportation contributes to lack of access to mental health services. Access to local mental health services may also be an issue of location and availability of adequate services.
Factors Related to the Provider
Primary Care Providers
Few PCPs would claim expertise in mental health care, yet the majority of older adults receive mental health care from their PCPs (Robinson, Geske, Prest, & Barnacle, 2005). While it is feasible for individuals to receive mental health services from their PCP for common, acute mental health problems, chronic or recurrent problems may be better managed by mental health specialists. Major barriers to receiving appropriate care may be a PCP’s lack of recognition that a mental health problem exists, inadequate treatment, and lack of referral to a mental health specialist when needed (Bower & Gilbody, 2005).
There is growing awareness among PCPs of the issues associated with comorbid physical and mental health conditions. Education regarding early recognition of symptoms, initial treatment, and ongoing management of common mental health problems for older adults is critical. For example, Stein et al. (2004) reported that PCPs are more likely now than in the past to recognize and treat depression due to the recent focus on provider education. However, mental health services are underused, and the availability of diagnostic and treatment services by mental health providers is lacking (Bartels et al., 2004).
PCPs are burdened with large numbers of patients, the management of complex medical problems, and multiple interruptions during patient care visits. Using videorecordings to capture office visits of PCP-patient interactions, Tai-Seale, McGuire, Colenda, Rosen, and Cook (2007) found that mental health topics were discussed in only 22% of visits and that these discussions lasted approximately 2 minutes. PCPs are frustrated with the knowledge and skills they need to provide high-quality care to their patients (Bodenheimer, 2006). There are long waits for individuals to be seen by PCPs, and patient visits are often short and rushed, which may have a negative impact on quality of care (Bodenheimer, 2006).
The American Psychiatric Association’s (2006) Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006 provides evidence-based recommendations for the assessment and treatment of psychiatric disorders. Pharmacological assessment and treatment require rigorous follow up to evaluate adverse effects and responses to treatment. Further, these guidelines call for combining pharmacological interventions with other psychotherapeutic interventions that are not readily available in primary care offices. Busy primary care practices may be a barrier to frequent mental health follow up, and lack of mental health resources for referral may further diminish positive outcomes.
Mental Health Providers
There are currently too few mental health providers, and many are not geographically accessible to older adults in need of services. Ellis, Konrad, Thomas, and Morrissey (2009) compiled national data on the number and placement of licensed mental health professionals and found slightly more than 350,000 clinically active licensed mental health providers in the country, the majority providing services in “urban, high-population, high-income counties and aside from marriage and family therapists they were concentrated in the northeast” (p. 1319). Psychiatrists and advanced practice nurses constituted the smallest number of clinicians in practice, which is problematic, considering the physiological basis of many mental health conditions and current treatment guidelines calling for combined pharmacological and psychosocial approaches (Ellis et al., 2009).
Quality mental health care may be inaccessible for the majority of older adults in the nation. Given the geographical placement and inadequate numbers of mental health professionals, older adults in rural areas may have no access to mental health care, and those in urban areas may have long waits for initial appointments. In a recent survey of PCPs, Cunningham (2009) reported that two thirds could not arrange for adequate mental health services for patients and that this was twice as high than for any other specialty. This represents a significant problem for PCPs, because lack of adequate mental health care often results in adverse outcomes. Mental Health America (2007) evaluated suicide rates across states and reported that a higher number of mental health providers per capita was associated with lower suicide rates.
Factors Related to the Health Care System
In addition to individual- and provider-related problems, several important systems issues interfere with older adults’ ability to obtain appropriate mental health care. Issues related to reimbursement of all health care services need to be addressed on a national level. Diagnostic tests and assessments are often paid at a higher rate than mental health care, and quantity of care versus quality are often rewarded (Bodenheimer, 2006). While “pay for performance” is a rapidly expanding strategy to improve the health care of individuals (Bremer, Scholle, Keyser, Houtsinger, & Pincus, 2008), there is no clear strategy for implementation. One performance indicator could be the location of PCPs in close proximity to mental health specialists. While collaborative models may be superior for improving communication among various providers, availability of mental health services near PCP practices would increase older adult access to mental health care. This may be a challenge, however, given the limited number of licensed mental health professionals.
Medicare’s fee-for-service option does support mental health care for older adults when needed. However, many older adults choose Medicare-managed health plans that regulate how mental health services are delivered and who delivers them. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 mandates that mental health problems are covered at the same level as other health problems. However, behavioral health is often subcontracted to managed behavioral health organizations, which further limits access to specific providers or provider organizations (Cuellar & Haas-Wilson, 2009). Older adults in lower socioeconomic groups have added difficulty accessing mental health care. Medicaid is the single largest payer of mental health care for low-income individuals of all ages (Cunningham, McKenzie, & Taylor, 2006). While Medicaid benefits provide for coverage, many providers limit the number of Medicaid patients in their practice due to lower levels of reimbursement.
In addition, older adults with complex health problems may be homebound. Medicare allows for home health services, yet the fee structure makes it impossible to receive in-home mental health care by a licensed mental health professional. Those with managed care plans will undoubtedly be unable to access approved providers because of their homebound status. These isolated individuals who have complex health problems may be taking multiple medications and are clearly at risk for poor functional outcomes, rehospitalization, and increased morbidity and mortality, yet they have little access to mental health services (Knight & Houseman, 2008).
Reducing the barriers to older adults’ access to mental health care must become a national priority. As the number of individuals older than 65 continues to increase, so will the number of individuals with mental health problems. Poor health outcomes are associated with lack of access to mental health care for those with mental health problems. Older adults may experience a range of psychiatric and cognitive problems that not only affect their health status but also their ability to participate actively in self-care.
Education of older adults, family members, and the community is paramount. National media campaigns can draw attention to common mental health problems and identify available resources. Older adults of all ages need assistance identifying key entry points into the mental health system due to lack of experience, stigma, and difficulty physically accessing services (Horgan et al., 2009). Community agencies need to become more aware of the mental health needs of community members and provide current information about local resources.
Despite busy practices and large numbers of patients, PCPs must routinely screen for mental health problems and be aware of up-to-date information on the management of common and acute mental health problems in older adults. Pharmacological interventions are often a primary mode of treatment. Evidence on the safety and efficacy of new agents and possible interactions must be integrated into practice. Identifying and developing working relationships with mental health practitioners within the geographical area of PCPs can improve access and communication.
Distance to treatment sites has been cited as a barrier to seeking mental health care (Gonzalez, Williams, Noël, & Lee, 2005). Access to mental health care providers at the point of primary care access is an effective approach to improve mental health outcomes (Bower & Gilbody, 2005). Collaborative models place psychiatric care providers in the same practice or in the practice environment of PCPs. This further reduces problems associated with communication among providers, improves patient convenience, and may improve screening for mental health problems on the basis of the availability of a collaborating mental health clinician. The health care system needs to identify strategies to reward providers who collaborate and demonstrate reduced time from referral to consultation or appointment with a mental health care provider.
Increased recognition of mental health problems generates a greater need for referrals to mental health care providers. The inadequate number of licensed mental health clinicians must be addressed at the systems level. Financial incentives for specializing in mental health care and for locating practices in geographical areas that are underserved may increase the workforce in those areas. Strategies to attract culturally diverse providers are also needed. Understanding the symptom experience from distinct cultural perspectives may increase treatment adherence. It is not clear whether evidence-based care developed for White middle-class Americans is effective for ethnic minorities (McGuire & Miranda, 2008). A focus on providing culturally competent mental health care is important in educational programs preparing mental health care providers.
Psychiatric home care by licensed mental health practitioners needs to be reimbursed at an appropriate level. Medicare recognizes all RNs with “psychiatric experience” as being able to provide mental health care to patients. They are reimbursed through home health benefits at the skilled nursing rate. While these nurses may have basic skills, homebound older adults with identified mental health problems need the knowledge and expertise of psychiatric clinical specialists and nurse practitioners to oversee and manage their mental health care. Developing reimbursement systems that allow home health and community agencies to provide quality care to this disparate population is critical. Adequate and appropriate mental health care for homebound older adults is currently nonexistent.
Finally, in addition to improved mental health care access, case management and social supports are necessary to maximize outcomes for older adults (Areán et al., 2008). Linking medical, psychiatric, and community resources is necessary as we move into an era where adults older than 65 will account for 20% of the population.
Efforts to reduce barriers for quality mental health care for older adults must be approached from multiple perspectives. Communities and health care organizations need to work together closely to develop education programs, identify community need and available resources, and improve communication and collaboration among agencies and providers. Regulatory agencies, Medicare, Medicaid, private insurers, and managed health plans must carefully evaluate those policies and practices that may restrict access. Further, the availability of case management for those individuals with complex health and mental health problems deserves serious consideration. Efforts to develop and implement creative models to provide access to mental health services for this vulnerable population are a critical need.
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