Community Integration for Older Adults with Mental Illnesses: Overcoming Barriers and Seizing Opportunities

Moving older adults from institutions, which may have been their “home” for most of their lives, to the community presents a unique set of challenges. Until recently, nursing facility placement was the most common, and in some cases the only, long-term care option for older adults considered in many States. This was in large part due to the lack of community-based alternatives in general, and residential options in particular.

The Federal and State emphasis on children and younger adults with mental disorders— who are more mobile and visible and have had more effective advocates—has also been a factor in lack of attention to older adults. Mental health advocates for older adults have just begun to draw attention to the needs of this population and are only now beginning to convince policymakers to address these needs.

The Olmstead decision has helped bring to light the lack of attention States have given to alternatives to institutionalization for older adults with serious mental illnesses. This section highlights specific barriers to the development of a range of residential options, treatment, and support services that help older adults with mental illnesses leave institutional care and succeed in the community, or prevent inappropriate institutionalization. Fiscal and related Federal policy barriers are part of this discussion.

Fiscal Barriers

Compared to general health care, mental health is underfunded in all State and Federal programs, as well as in private insurance. There is a continuing push and pull among the various stakeholders for scarce dollars that must be shared among children’s services, adult services, and services for older adults with mental health needs. As a result, older adults with serious mental illnesses often are shortchanged.

Current reimbursement and financial policies tend to favor inpatient versus outpatient care; medical versus psychological care; acute versus chronic care; and more restrictive versus less restrictive care (Estes, 1995). In particular, the primary sources of funding for people with serious mental illnesses and for older adults, Medicaid and Medicare, respectively, offer incomplete coverage for older adults with mental health disorders. Medicaid funding is focused largely on institutional services, and Medicare coverage for mental health services is limited. Older adults with serious mental illnesses are vulnerable to being underserved in managed care arrangements.

Medicaid

Medicaid is the largest payer of institutional care for older adults with mental illnesses. The high cost of nursing home care quickly depletes the savings of most residents, and since Medicare does not contain a long-term care benefit, most nursing home residents eventually must rely on Medicaid. In 1998, nursing home care accounted for $44 billion of the $174 billion Medicaid budget. Overall, Medicaid funds 46 percent of nursing home expenditures (HCFA, 2000a).

The Medicaid program is a partnership between the Federal government and State governments to pay for health care for economically disadvantaged individuals and those with disabilities, with States contributing up to 50 percent of the costs. The Federal/State Medicaid match is formula-based and varies among States. Eligibility standards and extent of covered services also vary greatly from State to State. While Medicaid enables States to use Federal funds to provide health and mental health care for low-income residents, the mandated State match makes some legislatures reluctant to add services or broaden eligibility.

Medicaid is an entitlement program, meaning that there are certain basic services (“mandated services”) that a State participating in the Medicaid program must provide when the services are deemed medically necessary for an eligible recipient’s care. Nursing facility services are a mandated service under the Medicaid program, but Medicaid funding policies discourage the provision of specialty mental health services in nursing homes (U.S. Department of Health and Human Services, 1999).

States may elect to provide optional services, though provision of these services across the States is limited and uneven (Bartels & Smyer, 2002). The most common option for mental health services is the Medicaid Rehabilitation Option, which offers more flexibility in the services that are provided and in the types of professionals that can provide the services. The rehab option is popular with States both because of its flexibility and because of the State’s ability to limit coverage to selected groups.

Home and Community-Based Services (HCBS) waivers are a Medicaid optional service that allows States to develop alternative community-based services to prevent unnecessary institutional placements and to facilitate the discharge of residents from institutions. States must demonstrate that the cost of such services would not exceed the cost to Medicaid of the covered institutional services. All States have some HCBS waivers, and most use them to serve older adults and people with physical disabilities (General Accounting Office, 1995). Few States have requested HCBS waivers for individuals with chronic mental illnesses (Lutzky et al., 2000).

Medicare

Unlike Medicaid, which is a Federal/State partnership, Medicare is funded by the Federal government. Medicare is the largest funding source for health care provided to older adults. However, only 0.57 percent of total Medicare expenditures are for mental health services (Bartels & Smyer, 2002).

Within each State, Medicare contracts with a local health care insurer to administer the program. The State entity, commonly referred to as a “carrier” or sometimes an “intermediary,” has significant flexibility in establishing coverage policy. Medicare reforms in recent years have increased access to outpatient services, but less than one percent of Medicare mental health expenditures are for older adults in noninstitutional settings (Colenda et al., 2002).

Medicare beneficiaries access services through Medicare-approved health care providers. Medicare provides 80 percent payment for medically based services, resulting in a 20 percent copayment requirement. For nonmedical mental health services, such as psychotherapy, Medicare covers only 50 percent, requiring a 50 percent copayment. Approximately 14 percent of Medicare beneficiaries have no supplemental insurance and pay this copayment out-of-pocket.

Those who have supplemental insurance include those who buy it on their own, those who receive it as a retirement benefit, or those who are covered under Medicaid as “dual eligibles.” Dual eligibles (those who are covered under both Medicare and Medicaid) comprise approximately 16.5 percent of Medicare beneficiaries and 19 percent of all Medicaid beneficiaries (HCFA, 2000a, 2000b).

Mental Health Parity

Since virtually all older Americans participate in the Medicare program, the issue of parity (i.e., equal coverage for physical and mental health services) is of critical importance. Historically, insurance coverage in both the public and private sectors has not adequately covered mental health services.

One reason used to justify this over the years was the fear that the cost, particularly to insurance companies and employers, would substantially increase if mental health services were fully covered. Recent research, however, has shown that parity for mental health care results in negligible cost increases when care is managed (U.S. Department of Health and Human Services, 1999). Another factor was the perception that many mental health services were not really “medically necessary.”

During the 1990s advocacy efforts to achieve parity for coverage of mental health services increased, leading to passage of legislation nationally and in many States. Although this was an important step forward, broad-based parity has not been achieved. Opponents of mental health parity have successfully placed limitations and exemptions on the enacted legislation. For example, small businesses have been exempted under most plans. Employers can “opt out” if they can demonstrate that the increased cost of providing the coverage will exceed a specified percentage (Shea, 2002).

Furthermore, laws often fail to mandate mental health coverage, with parity required only if the insurance plan elects to cover mental health services. Though advocates feared that insurance plans would drop coverage of mental health services rather than provide parity coverage, it appears this has not happened, probably because the actual cost has been less than expected (Sing et al., 1998).

Prescription Drug Costs

Many effective medications are available to treat mental health disorders, including some newer drugs that are less likely to have the significant side effects associated with older drugs used to treat mental illnesses. However, until recently, Medicare did not provide a prescription drug benefit. Advocates for prescription drug coverage argue that this resulted in many low-income older adults having to choose between food and other essential needs, and paying for their medications. This is a particular burden on older adults with mental health disorders.

The Medicare Modernization Act (MMA), signed in December of 2003, provides a first step towards a comprehensive Medicare pharmacy benefit. The prescription drug benefit allows Medicare beneficiaries to enroll in a prescription drug plan, with Medicare paying 75 percent of the premium. Enrollment in the prescription drug plan will begin in the fall of 2005, with benefits scheduled to start in January 2006, and prescription drug discount cards are currently provided as a transitional benefit. Despite the passage of the MMA, older adults may continue to have inadequate access to mental health drugs due to potential cost-sharing requirements and restrictive formularies. Older adults who are dually eligible for Medicaid and Medicare may actually experience increased copayments and reduced access to specific prescription drugs.

Medicare beneficiaries have had mixed reactions to the MMA. A recent survey suggests that only 26 percent of Medicare beneficiaries have a favorable impression of the Medicare drug benefit. These beneficiaries envisioned that the program would be helpful to low-income persons as well as those with high prescription drug bills, would help pay for many of the prescription drug bills, and would allow persons to choose a prescription drug plan that best met their needs. However, 47 percent of beneficiaries had an unfavorable impression of the drug benefit as they felt it did not provide enough help with prescription drug costs, was too complicated to understand, and provided too much benefit to private health plans and pharmaceutical companies (Kaiser Family Foundation & Harvard School of Public Health, 2004). Moreover, only one-third of beneficiaries thought that the interim drug discount cards were helpful. In contrast, over half (55 percent) felt that the cards weren’t worth the trouble because they didn’t go far enough to help with prescription costs and were too confusing (Kaiser Family Foundation & Harvard School of Public Health, 2004).

Even for individuals who have prescription drug coverage, many of the newer medications may be unavailable or too costly through their insurance plans. Some are quite a bit more expensive than older drugs. Typically, health insurers establish policies that provide financial incentives, such as discounts or penalties, including higher copays, to encourage the use of generic drugs. Some Medicaid plans may require that individuals “fail” on the older medications before being allowed to try the newer drugs. These factors limit the availability of the latest and most effective drug treatments for older adults with serious mental illnesses.

Managed Care

The increasing reliance on managed care, particularly within Medicaid and Medicare programs, holds both promise and perils for older adults with serious mental illnesses. About 40 percent of Medicaid enrollees and 15 percent of the Medicare population are in managed care plans. Estimates are that 35 percent of all Medicare beneficiaries (15.3 million people) will be in managed care plans by 2007 (U.S. Administration on Aging, 2001).

The promise of managed care is lower costs and better coordination of care, but results are mixed, especially for vulnerable populations. The Surgeon General’s report on mental health notes that managed care geriatric programs and clinical case management for older people are inadequate or poorly implemented (U.S. Department of Health and Human Services, 1999). Managed care plans have been criticized for lack of the array of community support and residential rehabilitation options for people with serious mental illnesses.

Managed care organizations that bear the financial risks for their enrollees’ care have an incentive to avoid older adults with serious mental illnesses, who have comprehensive, long-term treatment needs. Those plans in which mental health is “carved out” from physical health care have a difficult time coordinating care for older individuals with both medical and mental illnesses.

Clinical outcomes in managed care plans are mixed. People most likely to have negative outcomes include individuals with chronic conditions, those with low incomes who are in worse health, and older people who are frail or impaired. These characteristics also are commonly associated with older adults with serious mental illnesses (U.S. Administration on Aging, 2001). At least one observer has noted that there are “no known successful models of HMO care to severely mentally ill elderly people” (Knight & Kaskie, 1995).

Service System Barriers

Older adults seeking mental health services—especially community-based services—often encounter service system barriers that undermine both the quality of and access to effective services. Some of these barriers are directly related to the funding problems described in the previous section, but others are inherent in the structure and interaction of the service systems themselves.

Fragmented Systems of Care

The system of care for older adults with mental disorders has been described as a “‘non-system of care,’ plagued by irrational incentives and multiple access barriers” (Colenda et al., 2002). The emphasis is on cost reduction rather than on systems integration. A fragmented and underfunded system of care is hardly ideal for providing even a safety net for fragile individuals who are attempting to move to a less restrictive setting and live more independently.

Older adults with serious mental illnesses are especially vulnerable to falling through the cracks of a fragmented system of care. They deal with multiple and distinct care systems—including medical care, long-term care, mental health services, aging network services, and dementia care services—each with its own operating principles and reason for being (Knight & Kaskie, 1995). No one agency is responsible for coordinating care for older adults with serious mental illnesses.

In an era of increasing needs and decreasing resources, mental health and aging services programs are under enormous economic pressure to compete for funds and to cut costs by dealing with existing clients only. Mental health providers focus on people with mental disorders, and aging services program focus on older adults. This approach is not conducive to caring for older adults with serious mental illnesses, especially those with lengthy histories of institutional care, who require multiple, coordinated, and intensive long-term services.

Fragmentation in service delivery for older adults with serious mental illnesses is especially problematic in two areas: lack of coordination with primary care providers and lack of discharge planning. Each is discussed in brief below.

Lack of Coordination with Primary Care

More than half of older people who receive mental health care are treated by their primary care provider (U.S. Administration on Aging, 2001). This may be especially true for older adults who are members of minority groups.

The advantages of primary care for older adults include proximity, affordability, convenience, and coordination of mental and medical disorders. Also, older adults feel less stigmatized seeking help from a primary care provider than from a mental health provider (U.S. Department of Health and Human Services, 1999; Colenda et al., 2002).

However, the rate at which primary care providers identify mental disorders in older adults is extremely low. Primary care practitioners receive insufficient training in mental health and in geriatric assessment and care, and they frequently attribute psychiatric symptoms to aging or to physical disorders (U.S. Administration on Aging, 2001). Assessment is difficult, particularly when medical disorders mimic or mask psychopathology (see “Clinical Barriers” in this section).

Primary care providers have been criticized for relying excessively on medications to treat their older patients with mental disorders, for spending little time on counseling, and for making few referrals to mental health professionals when a mental disorder is identified (Estes, 1995; Colenda et al., 2002). New models of cooperation between primary care and mental health services are discussed in the final section of this report.

Lack of Discharge Planning

Psychiatric hospital stays are increasingly shorter, and, ideally, individuals should be prepared for discharge beginning at admission. Unfortunately, shorter stays mean that some individuals with serious mental illnesses are released before their symptoms are adequately stabilized. In the absence of a good discharge plan, even individuals who are ready to leave are at risk for repeat institutionalization and possible homelessness.

A lack of coordination between the hospital and other community-based providers to ensure appropriate housing, treatment, income, and supports may be especially problematic for older adults who have been institutionalized for lengthy periods of time and who have come to depend on the hospital or nursing home to meet all of their daily needs. Skills such as food shopping and preparation, personal grooming, and paying bills may be unknown or forgotten. These deficits can impede life in the community. Effective discharge planning as a prevention strategy is discussed in the next section.

Lack of Appropriate Residential and Community-Based Services

Older adults with serious mental illnesses want and need the same types of services and supports that their younger counterparts desire. In a study of older adults with serious mental illnesses in Thunder Bay, Ontario, participants cited the need for a meaningful, productive life; safe and secure housing; social networks; and individualized programs (Tryssenaar et al., 2002). Lack of such services impedes their recovery and their ability to live successfully in the community.

Lack of Services

While effective housing and service programs with well-qualified staff are available in certain locations, they remain the exception rather than the rule. In general, community mental health providers are not trained or funded to address the specific issues that face many older adults with mental health problems, including the need for housing, transportation, nutritional meals, and care for medical illnesses. Older adults represent 13 percent of the U.S. population but receive only 6 percent of community mental health services (U.S. Administration on Aging, 2001).

Many Community Mental Health Centers report no aging-specific programs or staff trained in geriatrics, and only 23 percent of CMHCs report having formal relationships with Area Agencies on Aging (Knight & Kaskie, 1995). Although few older adults present for specialty mental health services, in part due to stigma, only 15 percent of community mental health providers named older adults as a target group for outreach (Estes, 1995).

These factors are often further compounded by many older adults’ lack of skills and experience at organizing the resources needed to meet their needs. Case management, a key service for addressing theseneeds, is a Medicaid optional service that States can choose to provide. However, in nearly all States, case management is either used for younger mental health consumers or is limited to far fewer individuals than could benefit from the service.

Lack of Access to Services. Even when services are available, older adults with serious mental illnesses may not have access to them. Problems with access to adequate and appropriate mental health services were cited as one of the major concerns of the President’s Commission on Mental Health Subcommittee on Older Adults (Bartels, 2003). Many older adults no longer drive or have access to a car; others may be afraid to take public transportation (H. Gardiner, personal communication, November 12, 2002). Older adults who are especially frail may need to rely on special transportation services that are too expensive.

Access problems are compounded for older adults living in rural areas. Lack of trained providers and access to the newest treatments and medications are barriers for rural residents with serious mental illnesses, and older adults often must travel long distances to receive services.

Lack of ethnically diverse staff in both mental health and aging programs is a further barrier to treatment and support for older adults. The U.S. U.S. Administration on Aging (2001) reports an insufficient number of mental health professionals from ethnic minority groups. Language and cultural barriers may lead to inadequate services.

Lack of Housing

Most older adults with serious mental illnesses prefer to live independently in their own homes, and many do so successfully when they have access to a range of services and supports (Bartels, Miles, et al., 2003). Residential options will continue to be needed for some older adults with serious mental illnesses—especially for individuals with comorbid medical problems, physical limitations, developmental disabilities, and limited personal living skills. These individuals require some level of onsite support, but not the level of care provided in nursing facilities. While there is a growing understanding of the importance of individualized housing, scarce resources mean that a full range of options is rarely available.

In addition to nursing homes, many older adults with psychiatric disorders reside in other long-term care settings, including assisted living facilities, adult foster care homes, and board and care facilities. These facilities vary in quality and oversight. Those that have caring and well-trained staff and that are well-connected with area resources are excellent for that minority of people who prefer to live in a group setting. However, a lack of options and limited finances means that many individuals who would much rather live on their own must live in congregate, often low-quality facilities. Brief descriptions of several of these types of facilities follow.

Assisted Living Facilities. Assisted living facilities for older adults who need support to live in the community but who do not require institutionalization provide an assortment of long-term care options and services. Data from 1996 suggest that 30,000 to 65,000 assisted living facilities were operating in the United States; currently over a million older people reside in assisted living facilities (American Association of Homes and Services for the Aging, 2002). Most such facilities provide housing, meals, personal assistance, and medication reminders (Becker et al., 2002).

Prevalence rates of psychiatric disorders in assisted living facilities have not been systematically documented, but available data suggest that these settings are likely to house substantial numbers of older adults with cognitive impairment disorders, depression, and other psychiatric disorders. Most States license assisted living facilities but do not require them to screen for psychiatric illnesses or treat mental disorders, suggesting that there is substantial unmet need for treatment (Bartels, 2001; Becker et al., 2002).

In response, an increasing number of States are licensing assisted living facilities to provide mental health services. In Florida, for example, limited mental health licensure is required for facilities that admit three or more individuals with a mental disorder (Becker et al., 2002). However, without reimbursement for increased costs, many of these regulations will be unenforceable. Individuals living in homes that are not eligible for or choose not to apply for special licensing are at risk of being displaced and possibly institutionalized (Becker et al., 2002).

Medicaid provides limited resources for some older adults with mental illnesses residing in assisted living facilities. As of 2001, some services provided in assisted living facilities were covered under Medicaid in 39 States. However, as with most optional Medicaid services, reimbursement policies differ among States. In addition, although a State Medicaid program may support several reimbursable services, assisted living facilities are not required to provide all reimbursable services to their residents (Mollica, 2001).

With typical monthly rates of $2,000 to $4,000, many assisted living facilities are unaffordable for individuals with low incomes (American Association of Homes and Services for the Aging, 2002). Furthermore, residential services in assisted living facilities do not qualify for Medicaid reimbursement.

Adult Foster Care. Adult foster care ranges from residence in private homes to boarding houses or communal living arrangements. Originally developed for individuals with developmental disabilities, such programs meet the transportation, physical care, and other daily living needs of older adults unable to manage independently. These facilities are often seen as a less intensive alternative to nursing homes for older adults who are less impaired than typical nursing home residents (Mehrotra & Kosloski, 1991).

Generally, adult foster care costs less and restricts life less than does institutional care. Often funded through a contractual agreement with the State, the availability of adult foster care varies across the country. In addition, there is little consensus regarding program descriptions, consumers, goals, or measures of success across programs.

Board and Care Facilities. A substantial number of individuals with mental illnesses who have histories of treatment in State hospitals live in board and care homes, which provide residential services to individuals with limited financial means. These modest, privately owned facilities are often located in low-income communities and offer low-cost, long-term care services. Tenants typically receive a bed and regular meals; they may also receive laundry service, but little else.

Proprietors charge residents the amount of their monthly Social Security check, minus a small amount of spending money. Up to 25 percent of older adults living in board and care facilities have a diagnosable mental illness (Hopp, 1999); however, there is substantial regional variation. For instance, a recent report indicated that 83 percent of adult home residents in the Brookhaven complex in New York had a history of mental illness (Meyers, 2001). An investigative report by the New York Times called New York City adult homes “little more than psychiatric flophouses” (Levy, 2002).

Board and care facilities include nonmedical, community-based residential settings, such as group homes, adult homes, domiciliary homes, personal care homes, and rest homes (General Accounting Office, 1989). This setting is largely unregulated, and access to care is highly variable (Herd, 2001). Due to the minimal oversight, the quality of these facilities depends to a large extent on individual proprietors. For example, severe problems in the quality of psychiatric and general health care for individuals with serious mental illnesses in boarding homes in inner city New York was cited as a cause of high rates of mortality for this vulnerable population (Levy, 2002).

Lack of a Qualified Workforce

A consensus statement published in the Archives of General Psychiatry (Jeste et al., 1999) referred to the “upcoming crisis in geriatric mental health.” A primary concern is the current and future shortage of mental health professionals in general, and specifically those trained to work with older adults (Bartels, 2003; Van Citters & Bartels, 2004a).

The number of trained geriatric mental health specialists is insufficient to meet service demands. For example, there are approximately 2,425 board-certified geriatric psychiatrists and 200 to 700 geropsychologists. However, estimates suggest that at least 5,000 professionals are needed in each specialty to begin to address service demands (Jeste et al., 1999).

Many rural areas are already underserved by mental health professionals; those also specializing in working with older adults may not be available within hundreds of miles. For example, of Indiana’s 92 counties, 64 counties did not have a psychiatrist, 23 had no clinical psychologist, and 4 did not have a clinical social worker. Three counties had none of these professionals at all, according to a survey by the Indiana Division of Mental Health and Addiction in 1999. The situation in Indiana is not unique. Other States are facing similar shortages, particularly as budget cuts make it even more difficult to draw trained geriatric mental health professionals to rural areas.

While other countries, most notably Great Britain and Japan, have created significant numbers of geriatric departments in medical schools, the United States has not. An Alliance for Aging Research (2002) report indicates that only 3 out of 144 medical schools have geriatric departments. The United States has few Centers on Aging, and funding for Geriatric Education Centers has been reduced in recent years. This report also addresses current and future shortages of nurses, psychologists, pharmacists, physical therapists, and social workers with geriatric training.

The current and projected future shortage of mental health professionals points to the need for adequately trained paraprofessionals and other direct care workers. There is also rapid turnover among these workers, who play a central role in direct service to older adults with mental illnesses. Workers are undertrained, underpaid, and often work under stressful conditions. A combination of Federal and State policy changes and additional resources will be necessary to address this problem. For all these reasons, volunteers will play an increasingly important role in the care of older adults.

Clinical Barriers

A significant number of older adults with mental illnesses and substance abuse disorders remain unrecognized and untreated. The U.S. Administration on Aging (2001) recommends routine screening for cognitive, behavioral, and emotional disorders by health care providers in an effort to assure access to quality mental health care. Other authorities also recommend annual or regular screening for alcohol and substance abuse (CSAT, 1998). Screening of older adults for mental illnesses is complicated by their comorbid medical conditions, their tendency to express somatic complaints rather than psychiatric symptoms, and their preference for treatment in primary care rather than mental health settings (U.S. Department of Health and Human Services, 1999). Screening of older adults in institutions may focus on disabilities rather than strengths and may result in inappropriate treatment. Furthermore, failure to ascertain other potential support information (i.e., community, family) may result in premature long-term care facility placement when informal caregivers could support individuals in the community for a greater length of time. Screening alone, in the absence of specific training for physicians and adequate services to which they can refer patients, is not enough. For example, research shows that screening for depression or screening plus a psychiatric interview results in an increased number of recognized cases of depression and increased prescriptions for antidepressants, but does not relieve patient distress (Bartels, Coakley, et al., 2002; Oxman & Dietrich, 2002). Moreover, the U.S. Preventive Services Task Force (2002) recently recommended screening adults for depression, but only in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. However, systems to ensure effective care are rarely in place. Several large studies that are examining the provision of mental health services to older adults in primary care are detailed in the last section of this report.

Societal Barriers

Officially designated the “Decade of the Brain,” the 1990s were dedicated to enhancing public awareness about brain disorders and the benefits of brain research. Focused attention on mental health issues by the Surgeon General of the United States, combined with research and public awareness activities initiated by the National Institute of Mental Health, the Library of Congress, and SAMHSA worked to reduce the stigma of mental illnesses. However, stigma and discrimination, as well as a lack of attention to prevention research and services, remain significant barriers for older adults seeking mental health services.

Discrimination and Stigma

Older adults with serious mental illnesses face discrimination and stigma both for their mental health disorders and for their age. Ageism can reveal itself in benign neglect. For example, family members and physicians may view depression as a normal part of aging, or believe that a loved one or patient is too old to be treated for a substance abuse disorder. Or ageism may be more overt, as when older individuals are viewed as being no longer able to be productive on the job (U.S. Administration on Aging, 2001).

People with mental illnesses frequently are stigmatized by myths, sometimes perpetuated by media portrayals of mental illness, which view them as dangerous or incapable of recovery. Bias and fear, based on stigma, exists among families, neighborhoods, and society, as well as professionals and other service providers. Such attitudes can complicate successful community integration (U.S. Department of Health and Human Services, 1999).

Older adults themselves may internalize these attitudes and may fail to seek treatment for mental health problems. Fear of being labeled “insane,” of losing their independence, and the perceived shame associated with mental illness are all powerful incentives to avoid treatment, or even to learn about mental health issues. This may be especially true for older adults who came of age when treatments for mental illnesses were less effective than today and often regarded with fear (U.S. Administration on Aging, 2001).

The National Institute of Mental Health estimates that as few as 1 in 10 older adults with depression receive treatment (Lebowitz et al., 1997; National Institutes of Health, 1992). The significantly higher rate of suicide among those over the age of 65 has been partially attributed to older adults’ reluctance to seek mental health treatment (U.S. Department of Health and Human Services, 1999).

Finally, since deinstitutionalization began, the attitude of Not In My Back Yard (NIMBY) has influenced the development of community-based programs. Restrictive covenants, city ordinances, single-family zoning, State laws governing disability housing, and organized neighborhood protests are some of the ways communities act on their fears. Research has shown that concerns about property values, crime and violence, and public nuisances are based largely on misinformation and myths (U.S. Department of Health and Human Services, 1999).

Insufficient Attention to Prevention

It is less expensive and more humane to keep people from becoming ill than it is to treat them when they become sick. However, prevention research in mental health is in its infancy, and most efforts have focused on children and adolescents. The need for prevention of mental disorders and excess disability that may result from such disorders among adults and older adults is increasingly recognized. Some prevention efforts are described in the next section.