by Michael B. Friedman, LMSW

The rapid growth of the population of older adults in the U.S. raises grave concerns about the viability of the Social Security System and of Medicare. People worry about whether they will have enough money, where they will live, whether they will become disabled and need care, whether they will get the care they need, whether they will become isolated and ultimately die alone, whether they will end their lives in a nursing home. But in general they do not worry about mental health.

This is a big mistake. Mental health is key to aging well.

Of course, some people think that aging well is an oxymoron. They believe that aging is inherently depressing and frightening, that it inevitably makes people sad, tired, grumpy, and disinterested in life. In essence they believe that it's normal to be mentally ill when you're old.

But that's pure ageism. Only 20% of elders have mental disorders; 80% do not. Mental illness is not normal in old age, and it is usually treatable.

Yet, even for people who care about the well-being of older adults, mental health has been a low priority. Even for mental health professionals and advocates, the mental health of older adults has been a low priority. Just look at what these groups ask federal and state governments for every year. If you find geriatric mental health on their lists, it's for a pittance.

It's time to make geriatric mental health a front burner issue in America.

Here are the facts:
• From 2000 to 2030 the number of people 65+ will grow from 35 million to 70 million and from 13% of the population to 20%.
• Over this same period the number of older adults with mental illnesses will grow from approximately 7 million to approximately 14 million.
•During this period there will also be a significant increase in the proportion of minority older adults in the United States, rising from 16.5% of the elderly population in 2000 to 25.6% in 2030.

What needs to be done? This is not easy to answer because older adults with mental illnesses are a diverse population. Some people develop dementia as they age--often combined with depression and/or anxiety. Some are people with lifelong, severe psychiatric disabilities who are aging in a system of care that is not prepared to deal with their health problems, their needs for special housing, or their needs for rehabilitation geared to people of their age. Some people have severe anxiety and/or depression and are at great risk of social isolation, suicide, and removal from the community because of behaviors that service providers in the community have not been trained to manage. Some people have comparatively minor--but still very painful--anxiety or depressive disorders. Some people abuse substances. Very few abuse illegal substances, but many abuse alcohol, prescription drugs, and/or over the counter medications. And a great many people find it difficult to make the transition from working age to old age. They confront problems of shaping a new identity after they retire. They are often challenged by diminished (but usually not lost) physical and mental skills. Deaths of friends and family become increasingly common. And many people struggle with their own mortality and with how to maintain a sense of meaning or purpose.

Despite the heterogeneity of the population, there are a number of common issues affecting virtually all older adults with mental illnesses:

• Access: Fewer than half of older adults with diagnosable mental disorders get treatment at all, and of those fewer than half get services from mental health professionals. Why? In large part because there are too few services. And those that exist are often difficult to access because of location, shortage of home and community--based services, unaffordable cost, and the lack of bi-lingual providers.

• Outreach and public education: Low utilization of professional mental health services also reflects stigma, ignorance, and ageism. Outreach to engage older adults who need help and public education to encourage them to seek help are rare and very hard to fund.

• Quality: The quality of available services is very uneven. Many people go to primary care physicians, who reportedly provide minimally adequate services less than 12% of the time. Mental health professionals are better but reportedly provide minimally adequate services less than 50% of the time for all populations and even less frequently for older adults because of lack of specialized training. Mental health services in nursing homes and other institutional settings are also of very uneven quality, and health and aging service providers are generally not equipped to deal with mental illness.

•Integration health and mental health: Most older adults with mental illnesses also have chronic physical illnesses. In part this reflects the fact that older adults are more likely to have chronic illnesses, but in part it reflects an apparent correlation between mental and physical illness. Despite the availability of evidence-based models of integration, few integrated services are available.

•Integration of aging and mental health services: For all older adults activity and social involvement appear to be essential to maintaining and/or improving mental health. It is, therefore, critical to promote access to the social mainstream and to integrate mental health services with services provided through the "aging" system.

• Cultural competence: The rise in the numbers of minority older adults makes it more and more important to develop culturally competent services.

• Family support: Because families provide most of the supports which older, disabled adults need, it is critical to address the needs of family caregivers as well as the needs of those for whom they provide care.

•Research: To date, research has not produced ultimate insights or cures for mental illnesses among older adults. More research is critical.

•Positive aging: Ageist preconceptions notwithstanding, there are great opportunities for older adults to shape satisfying, creative, productive, and useful lives. Yet little is done to promote positive aging or to prevent mental illness.

•Workforce: There is a vast shortage of mental health professionals with expertise serving older adults. There is also a vast shortage of health and aging service providers to work with people with mental illness.

•Funding for mental health services is inadequate and discriminatory. For example Medicare reimburses less for mental illnesses than physical illnesses, limits access to prescription drugs, and does not cover the kinds of outreach and "wraparound" services that are vital to many people with severe psychiatric disabilities.

These issues define a set of challenges that will not be easy to meet. It is clear that we need more services, a larger and higher quality workforce, and funding to make all these necessary improvements.

But we also need:

• To craft a new vision of service and support, a vision which weaves together the clinical, the rehabilitative, the medical, the social, and the familial, and
• To address the fissures in the current structure of serving older adults and to bring together mental health, health, and aging systems

Small, but important, steps have been taken recently. There has been some recognition of the special needs of older adults with mental health problems at the federal level. New York State enacted the Geriatric Mental Health Act in 2005, establishing an Interagency Geriatric Mental Health Planning Council and a services demonstrations grants program with $2 million to begin the program. Grants for nine projects were announced in April 2007. All good news.

But it is just a beginning. We have "many miles to go before we sleep" if we are to fully meeting the mental health challenges of the elder boom.

For further information e-mail Mr. Friedman at center@mhaofnyc.org or visit www.mhawestchester.org/advocates/geriatrichome.asp.