Mental Health: A Report of the Surgeon General

services, and, in some cases, medical care. In short,
more resources must be devoted to programs that
integrate mental health rehabilitative services into
long-term care in both community and institutional
settings.

Financing Services for Older Adults
Financing policies furnish incentives that favor
utilization of some services over others (e.g., nursing
homes rather than state mental hospitals) or preclude
the provision of needed services (e.g., mental health
services in nursing homes). Details on financing and
organizing mental health services, with a special focus
on access, are presented in Chapter 6. Selected issues
germane to older adults are addressed here.

Historically, Federal financing policy has imposed
special limits on reimbursement for mental health
services. Medicaid precluded payment for care in so-
called "institutions for mental diseases," Medicaid's
term for mental hospitals and the small percentage of
nursing homes with specialized mental health services.
This Medicaid policy provided a disincentive for the
majority of nursing homes to specialize in delivering
mental health services for fear of losing Medicaid
payments (Taube et al., 1990). Under Medicare, the
most salient limits were higher copayments for
outpatient mental health services and a limited number
of days for hospital care. Medicare's special limits on
outpatient mental health services were changed over the
past decade, resulting in significantly increased access
to and utilization of such services (Goldman et al.,
1985; Rosenbach & Ammering, 1997). The concern,
however, is that the gains made as a result of policy
changes easily could be eroded by the shift to managed
care (Rosenbach & Ammering, 1997).

Increased Role of Managed Care

Projections are that 35 percent of all Medicare
beneficiaries will be in managed care plans by the year
2007, amounting to approximately 15.3 million people
(Komisar et al., 1997). Although the managed care
industry has the potential to provide a range of
integrated services for people with long-term care
needs, managed care's awareness of and response to

chronic care are rudimentary (Institute for Health and
Aging, 1996). Despite the potential of systems of
managed health care, such as HMOs, to provide
comprehensive preventive, acute, and chronic care
services, their current specialized geriatric programs
and clinical case management for older persons tend to
be inadequate or poorly implemented (Friedman &
Kane, 1993; Pacala et al., 1995; Kane et al., 1997). In
addition, older patients are likely to be poorly served in
primary care settings (including primary care HMOs)
because of minimal use of specialty providers and
suboptimal pharmacological management (Bartels et
al., 1997). Further, current systems lack the array of
community support, residential, and rehabilitative
services necessary to meet the needs of older persons
with more severe mental disorders (Knight et al., 1995).
These shortcomings are unlikely to be remedied until
more research becomes available demonstrating cost-
effective models for treating older people with mental
illness.

Carved-In Mental Health Services for Older
Adults

The types of mental health services available within
managed care organizations vary greatly with respect to
how services are provided. In some organizations,
mental health care is directly integrated into the
package of general health care services ("carved-in"
mental health services), while it is provided in others
through a contract with a separate specialty mental
health organization that provides only these services
and accepts the financial risk ("carved-out" mental
health services).

Proponents of carved-in mental health services
argue that this model better integrates physical and
mental health care, decreases barriers to mental health
care due to stigma, and is more likely to produce
cost-offsets and overall savings in general health care
expenditures. These features are particularly relevant to
older persons, as they commonly have comorbid
somatic disorders for which they take multiple
medications that may affect mental disorders, often
avoid specialty mental health settings. and incur
significant health care expenses related to psychiatric

376


symptoms (George, 1992: Paveza & Cohen, 1996;
soak. 1996; Riley et al., 1997). Unfortunately, mental
health specialty services for older persons tend to be a
low priority in managed health care organizations, by
comparison with medical or surgical specialty services
(Bartels et al., 1997). More importantly, carved-in
mental health care may have superior potential for
individuals with diagnoses such as minor depression
and anxiety disorders but tends to shortchange older
patients with SPMD who require intensive and long-
term mental health care (Mechanic, 1998). The range of
outreach, rehabilitative, residential, and intensive
services needed for patients with SPMD is likely to
exceed the capacity, expertise, and investment of most
general health care providers.

Economic factors also hay limit the usefulness of
mental health carve-ins in serving the needs of older
individuals with SPMD. First, evidence from private
sector health plans suggests that without mandated
parity, insurers offer inferior coverage of mental health
care (Frank et al., 1997b, 1997~). Furthermore, if
providers or payers compete for enrollees, there is
strong incentive to avoid enrollees expected to have
higher costs from mental health problems (e.g., older
persons with SPMD). To avoid such discrimination,
equal coverage of mental health care would have to be
mandated through legislation on mental health parity or
through specialized contract requirements with
managed care organizations.

Carved-Out Mental Health Services for Older
Adults
Proponents of mental health service carve-outs for
older persons argue that separate systems of financing
and services are likely to be superior for individuals
needing specialty mental health services, especially
those with SPMD. In particular, advocates suggest that
carved-out mental health organizations have superior
technical knowledge, specialized skills, a broader array
of services, greater numbers and varieties of mental
health providers with experience treating severe mental
disorders, and a willingness and commitment to service
high-risk populations (Riley et al., 1997). From an
economic perspective, since competition is largely over

Older Adults and Mental Health

the carve-out contract with the payer (generally a
public organization or an employer), there is less
incentive to compete on risk selection, and risk
adjustment becomes unnecessary. In addition, mental
health carve-out organizations may be better equipped
to provide rehabilitative and community support mental
health services necessary to care for older persons with
SPMD. Finally, growth of innovative outpatient
alternatives could be stimulated by reinvestment of
savings by the payer from any decrease in inpatient
service use.

Unfortunately, research is la'cking on outcomes and
costs for older persons with SPMD in mental health
carve-outs. A carve-out arrangement could lead to
adverse clinical outcomes in older patients due to
fragmentation of medical and mental health care
services in a population with high risk of complications
of comorbidity and polypharmacy. Also, from a
financial perspective, the combination of physical and
mental comorbidities seen in older adults, especially
those with SPMD, may reduce the economic
advantages of carved-out services (Bazemore, 1996;
Felker et al., 1996; Tsuang & Woolson, 1997). If the
provider cannot appropriately manage services and
costs associated with the combination of somatic and
mental health disorders, anticipated savings may not
materialize.  Furthermore,  fragmentation of
reimbursement streams would likely complicate the
assessment of cost-effectiveness or cost-offsets. For
example, apparent savings of mental health carve-outs
under Medicare actually may be due to shifting costs
when an individual is also covered under Medicaid. In
this situation, Medicaid may cover prescription drugs,
long-term care, and other services that are not paid for
by Medicare. In order to offer true efficiencies,
Medicare mental health carve-outs need to find a way
to bridge the fragmentation of financing care for older
persons.

Outcomes Under Managed Care

There do not appear to be any studies of mental health
outcomes for older adults under managed care. In
general, the available research on mental health
outcomes for other adults consistently finds that

377


Mental Health: A Report of the Surgeon General

managed care is successful at reducing mental health
care costs (Busch, 1997; Sturm, 1997), yet clinical
outcomes (especially for the most severely and
chronically ill) are mixed and difficult to interpret due
to differences in plans and populations served. Several
studies suggest that outcomes under managed care for
younger adults are as favorable as, or better than, those
under fee-for-service (Lurie et al., 1992; Cole et al.,
1994). In contrast, others report that the greater use of
nonspecialty services for mental health care under
managed care is associated with less cost-effective care
(Sturm & Wells, 1995), and that older and poor
chronically ill patients may have worse health
outcomes or outcomes that vary substantially by site
and patient characteristics (Ware et al., 1996). A recent
review of health outcomes for both older and younger
adults in the managed care literature (Miller & Luft,
1997) concluded that there were no consistent patterns
that suggested worse outcomes. However, negative
outcomes were more common in patients with chronic
conditions,  those with diseases requiring more
intensive services, low-income enrollees in worse
health, impaired or frail elderly, or home health patients
with chronic conditions and diseases. These risk factors
apply to older adults with SPMD, suggesting that this
group is at high risk for poor outcomes under managed
care programs that lack specialized long-term mental
health and support services. To definitively address the
question of mental health outcomes for older persons
under managed care, appropriate outcome measures for
older adults with mental illness will need to be
developed and implemented in the evolving health care
delivery systems (Bartels et al., in press).

Other Services and Supports
Older adults and their families depend on a multiplicity
of supports that extend beyond the health and mental
health care systems. Patients and caregivers need
access to education, support networks, support and self-
help groups. respite care, and human services, among
other supports (Scott-Lennox & George, 1996). These
services assume heightened importance for older
people who are living alone, who are uncomfortable
with formal mental health services, or who are

inadequately treated in primary care. Services and
supports appear to be instrumental not only for the
patient but also for the family caregiver, as this section
explains, but research on their efficacy is sparse. The
strongest evidence surrounds the efficacy of services
for family caregivers. Support for family caregivers is
crucial for their own health and mental health, as well
as for controlling the high costs of institutionalization
of the family member in their care. The longer the
patient remains home, the lower the total cost of
institutional care for those who eventually need it.

Support and Self-Help Groups
Support groups, which are an adjunct to formal
treatment, are designed to provide mutual support,
information, and a broader social network. They can be
professionally led by counselors or psychologists, but
when they are run by consumers* or family members,
they are known as self-help groups. The distinction is
somewhat clouded by the fact that mental health
professionals and community organizations often aid
self-help groups with logistical support, start-up
assistance, consultation, referrals, and education
(Waters, 1995). For example, self-help support groups
sponsored by the Alzheimer's Association use
professionals to provide consultation to groups
orchestrated by lay leaders.

Support groups for people with mental disorders
and their families have been found helpful for adults
(see Chapter 4). Participation in support groups,
including self-help groups, reduces feelings of
isolation, increases knowledge, and promotes coping
efforts. What little research has been conducted on
older people is generally positive but has been limited
mostly to caregivers (see later section) and widows (see
below), rather than to older people with mental
disorders.

Despite the scant body of research, there is reason
to believe that support and self-help group participation
is as beneficial, if not more beneficial, for older people
with mental disorders. Older people tend to live alone

' Consumers are people engaged in and served by mental health
services.

378


and to be more socially isolated than are other people.
They also are less comfortable with formal mental
health services. Therefore, social networks established
through support and self-help groups are thought to be
especially vital in preventing isolation and promoting
health. Support programs also can help reduce the
stigma associated with, mental illness, to foster early
detection of illnesses, and to improve compliance with
formal interventions.

Earlier sections of this chapter documented the
untoward consequences of prolonged bereavement:
severe emotional distress, adjustment disorders,
depression, and suicide. Outcomes have been studied
for two programs of self-help for bereavement. One
program, They Help Each Other Spiritually (THEOS),
had robust effects on those'who were more active in the
program. Those widows and widowers displayed the
improvements on health measures such as depression,
anxiety,  somatic  symptoms,  and self-esteem
(Lieberman & Videka-Sherman, 1986). The other
program, Widow to Widow: A Mutual Health Program
for the Widowed, was developed by Silverman (1988).
The evaluation in a controlled study found program
participants experienced fewer depressive symptoms
and recovered their activities and developed new
relationships more quickly (Vachon, 1979; Vachon et
al., 1980, 1982).

Education and Health Promotion

There is a need for improved consumer-oriented public
information to educate older persons about health
promotion and the nature of mental health problems in
aging. Understanding that mental health problems are
not inevitable and immutable concomitants of the aging
process, but problems that can be diagnosed, treated,
and prevented, empowers older persons to seek
treatment and contributes to more rapid diagnosis and
better treatment outcomes.

With respect to health promotion, older persons
also need information about strategies that they can
follow to maintain their mental health. Avoiding
disease and disability, sustaining high cognitive and
physical function, and engaging with life appear to be

Older Adults and Mental Health

important ways to promote mental and physical health
(Rowe & Kahn, 1997). The two are interdependent.

Established programs for health promotion in older
people include wellness programs, life review,
retirement, and bereavement groups (see review by
Waters, 1995). Although controlled evaluations of
these programs are infrequent, bereavement and life
review appear to be the best studied. Bereavement
groups produce beneficial results, as noted above, and
life review has been found to produce positive
outcomes in terms of stronger life satisfaction,
psychological well-being, self-esteem, and less
depression (Haight et al., 1998). Life review also was
investigated through individualized home visits to
homebound older people in the community who were
not depressed but suffered chronic health conditions.
Life review for these older people was found to
improve life satisfaction and psychological well-being
(Haight et al., 1998).

Another approach to promoting mental health is to
develop a "social portfolio," a program of sound
activities and interpersonal relationships that usher
individuals into old age (Cohen, 1995b). While people
in the modem work force are advised to plan for future
economic security-to strive for a balanced financial
portfolio-too little attention is paid to developing a
balanced social portfolio to help to plan for the future.
Ideally, such a program will balance individual with
group activities and high mobilir;v/energy activities
requiring significant physical exertion with lo+v
mobiZio/energy ones. The social portfolio is a mental
health promotion strategy for helping people develop
new strengths and satisfactions.

Families and Caregivers

Among the many myths about aging is that American
families do not care for their older members. Such
myths are based on isolated anecdotes as opposed to
aggregate data. Approximately 13 million caregivers,
most of whom are women, provide unpaid care to older
relatives (Biegel et al., 1991). Families are committed
to their older members and provide a spectrum of
assistance, from hands-on to monetary help (Bengston
et al., 1985; Sussman, 1985; Gatz et al., 199% Cohen,

379


Mental Health: A Report of the Surgeon General

1995a). Problems occur with older individuals who
have no children or spouse, thereby reducing the
opportunity to receive family aid. Problems also occur
with the "old-old," those over 85 whose children are
themselves old and, therefore, unable to provide the
same intensity of hands-on help that younger adult
children can provide. These special circumstances
highlight the need for careful attention to planning for
mental health service delivery to older individuals with
less access to family or informal support systems.

Conversely, a large and growing number of older
family members care for chronically mentally ill and
mentally retarded younger adults (Bengston et al.,
1985; Gatz et al., 1990; Eggebeen & Wilhelm, 1995).
Too little is known about ways to help the afflicted
younger individuals and their caregiving parents.
Families are eager to help themselves, and society
needs to find ways to better enable them to do so.

There is a great need to better educate families
about what they can do to help promote mental health
and to prevent and treat mental health problems in their
older family members. Families fall prey to negative
stereotypes that little can be done for late-life mental
health problems. They need to know that mental health
problems in later life, like physical health problems,
can be treated. They need to understand how to better
recognize symptoms or signals of impending mental
health problems among older adults so that they can
help their loved ones receive early interventions. They
need to know what services are available, where they
can be found, and how to help their older relatives
access such help when necessary.

The plight of family caregivers is pivotal. As noted
earlier, the burden of caring for an older family
member places caregivers at risk for mental and
physical disorders. Virtually all studies find elevated
levels of depressive symptomatology among caregivers,
and those using diagnostic interviews report high rates
of clinical depression and anxiety (Schultz et al., 1995).
Ensuring their mental and physical health is not only
vital for their well-being but also is vital for the older
people in their care. Support groups and services aimed
at caregivers can improve their health and quality of

life, can improve management of patients in their care,
and can delay their institutionalization.

Communities and Social Services
Family support is often supplemented by enduring
long-term relationships between older people and their
neighbors and community, including religious, civic,
and public organizations (Scott-Lennox & George,
1996). Linkages to these organizations instill a sense of
belonging and companionship. Such linkages also
provide a safety net, enabling some older people to live
independently in spite of functional decline.

While the vast majority of frail and homebound
older people receive quality care at home, abuse does
occur. Estimates vary, but most studies find rates of
abuse by caregivers (either family or nonfamily
members) to range up to 5 percent (Coyne et al., 1993;
Scott-Lennox & George, 1996). Abuse is generally
defined in terms of being either physical,
psychological, legal, or financial. The abuse is most
likely to occur when the patient has dementia or late-
life depression, conditions that impart relatively high
psychological and physical burdens on caregivers
(Coyne et al., 1993). A recent report by the Institute of
Medicine describes the range of interventions for
protection against abuse of older people, including
caregiver participation in support groups and training
programs for behavioral management (especially for
Alzheimer's disease) and social services programs
(e.g.. adult protective services, casework, advocacy
services, and out-of-home placements). While there are
very few controlled evaluations of these services (IOM,
1998), communities need to ensure that there are
programs in place to prevent abuse of older people.
Programs can incorporate any of a number of effective
psychosocial and support interventions for patients
with Alzheimer's disease and their caregivers-
interventions that were presented earlier in this section
and the section on Alzheimer's disease.

Communities need to ensure the availability of
adult day care and other forms of respite services to aid
caregivers striving to care for family members at home.
They also can provide assistance to self-help and other
support programs for patients and caregivers. In the

380


process of facilitating or providing services,
communities need to consider the diversity of their
older residents-racial and ethnic diversity, socio-
economic diversity, diversity in settings where they
live, and diversity in levels of general functioning.
Such diversity demands comprehensive program
planning, information and referral services (including
directories of what is available in the community),
strong outreach initiatives, and concerted ways to
promote accessibility. Moreover, each component of
the community-based delivery system targeting older
adults should incorporate a clear focus on mental
health. Too often, attention to mental health services
for older people and their caregivers is negligible or
absent, despite the fact, as noted earlier, that mental
health problems and care$ver distress are among the
leading reasons for institutionalization (Lombardo,
1994). Important life tasks remain for individuals as
they age. Older individuals continue to learn and
contribute to society, in spite of physiologic changes
due to aging and increasing health problems.

Conclusions

1.

2.

3.

4.

5.

Important life tasks remain for individuals as they
age. Older individuals continue to ,learn and
contribute to the society, in spite of physiologic
changes due to aging and increasing health
problems.

Continued intellectual, social. and physical activity
throughout the life cycle are important for the
maintenance of mental health in late life.

Stressful life events, such as declining health
and/or the loss of mates, family members, or
friends often increase with age. However,
persistent bereavement or serious depression is not
"normal" and should be treated.

Normal aging is not characterized by mental or
cognitive disorders.  Mental or substance use
disorders that present alone or co-occur should be
recognized and treated as illnesses,
Disability due to mental illness in individuals over
65 years old will become a major public health
problem in the near future because of demographic
changes. In particular, dementia, depression, and

Older Adults and Mental Health

schizophrenia, among other conditions, will all
present special problems in this age group:

  a.  Dementia produces significant dependency and
   is a leading contributor to the need for costly
   long-term care in the last years of life;
b. Depression contributes to the high rates of
   suicide among males in this population; and
c. Schizophrenia continues to be disabling in
   spite of recovery of function by some
    individuals in mid to late life.
6. There are effective interventions for most mental
disorders experienced by older persons (for
example, depression and anxiety), and many
mental health problems, such as bereavement.
7. Older individuals can benefit from the advances in
psychotherapy, medication, and other treatment
interventions for mental disorders enjoyed by
younger adults,  when these interventions are
modified for age and health status.
8. Treating older adults with mental disorders accrues
other benefits to overall health by improving the
interest and ability of individuals to care for
themselves and follow their primary care
provider's directions and advice, particularly about
taking medications.

9. Primary care practitioners are a critical link in
identifying and addressing mental disorders in
older adults. Opportunities are missed to improve
mental health and general medical outcomes when
mental illness is underrecognized and undertreated
in primary care settings.

10. Barriers to access exist in the organization and
financing of services for aging citizens. There are
specific problems with Medicare, Medicaid,
nursing homes, and managed care.

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