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Older Adults with Mental Illnesses Are Not Receiving Care

Depression is alarmingly common among older adults. About 5-10 percent of older adults have major depression, yet most are not properly recognized and treated (DHHS, 1999). Untreated depression causes distress, disability, and, most tragically, suicide. Older men have the highest rates of suicide in the Nation (IOM, 2002). Most worrisome is that the growing number of older Americans will soon magnify and expose existing problems.

"The US population will look like Florida very soon."
   —Stephen Bartels, M.D., M.S., Dartmouth Medical School

Older adults (age 65 or above) manifest depression in different ways than do younger adults, and they are reluctant to get care from specialists (DHHS, 1999). Instead, older people feel more comfortable going to their primary care doctor. Still, they are often more sensitive to the stigma of mental illness, and do not readily bring up their sadness and despair, their feelings of hopelessness and loss. If they acknowledge problems, they are more likely than young people to describe physical symptoms. Primary care doctors may see their suffering as "natural" aging, or treat their reported physical distress instead of the underlying mental disorder. What is often missed is the deep impact of depression on older persons' capacity to function in ways that are seemingly effortless for others.

Model Program

A novel research project, known as IMPACT, is designed to help primary care doctors spot depression and stop it in its tracks (Box 8). IMPACT⁵ is a multi-site clinical trial that delivers treatment in primary care settings to older people with major depression. In most settings, primary care doctors are on their own to detect and treat mental illness—as well as other ailments—in older adults. With IMPACT, a mental health professional (nurse, social worker, or psychologist) is added to the medical team. IMPACT gives older people the treatment they need—a choice of medications and/or psychotherapy. If those older people receiving their choice of care do not get better, a stepped up approach is offered, supervised by a psychiatrist. The study's preliminary findings are that the intervention, compared with usual care, leads to reduced prevalence and severity of symptoms, or complete remission. The Commission will examine whether existing reimbursement mechanisms are adequate to support broader use of this cost-effective approach.

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