Mental health and treatment more complicated for older adults

Oct. 26--ROCHESTER -- Looking back, Tammy Cervelli can see how her life was impacted by mental illness even as a teenager.

The Industry woman was diagnosed with bipolar disorder in her mid-30s, but ups and downs during adolescence probably were early signs, she said.

"Nobody knew. You were just a teenager," Cervelli said.

For years, Cervelli worked in the medical field, operated her own business, exercised and was an avid golfer. "I was always going, going, going ... and I would go continuously on about two hours of sleep a night," she said.

But at 34, she "fell apart."

Doctors prescribed various medications -- some helped, some didn't -- and Cervelli was able to work on and off for a while. Ultimately, she had to step away from her 20-year career and focus on her recovery journey.

Cervelli learned to manage her mental illness and now is assistant director of the Beaver County Mental Health Association's Phoenix Drop-In Center in Rochester, where she has worked for about 13 years.

She is only 55, but thinks a lot about what life will be like when she grows older.

"I don't know what's going to happen to me," she said. "My future seems bleak sometimes."

Cervelli has a supportive team around her and insurance that covers a private therapist and her medications, but she knows many people don't have the same access to care. She also noted that she expects her coverage could change soon.

"There's a lot of challenges for people who have mental health issues and aren't as fortunate as me," she said.

And as people age, the challenges involved in treating and preventing mental illness and keeping them healthy physically become even more complex.

'Not just the blues'

Certain things are simply common parts of growing older -- aches and pains, children leaving the nest, loss of older friends or family members and retirement.

Sometimes these things can be difficult to accept, and they can lead to mental illness such as depression, which, while also common, is not a normal part of aging, according to the National Institute of Mental Health and the U.S. Centers for Disease Control and Prevention.

Dr. Charles Reynolds III, UPMC endowed professor of geriatric psychiatry at the University of Pittsburgh School of Medicine, said that in his experience, about half of older adults with depression or anxiety have a history of mental illness, while the other half develop it for the first time in later life.

Mental illnesses are medical conditions that can affect people of any age, and typically involve changes to thinking, mood, daily functions, ability to make choices and behavior, according to the National Alliance for Mental Illness.

Rates of major depression -- a serious mental illness that involves depressed mood or loss of interest or pleasure over a two-week period along with several other symptoms or impairment -- are higher in younger populations, according to the CDC. But other, less severe conditions, such as minor depression and dysthymic disorder, are more common among older adults.

Estimates for the different conditions vary, but about 25 percent of adults age 65 or older have some type of mental health problem, according to the CDC.

Feelings of grief and bereavement, financial stress and other worries, a loss of identity after leaving the workforce, loneliness or worthlessness, as well as biological and medical factors often contribute, said Reynolds, who also is director of the Aging Institute of UPMC and Pitt.

Older adults also may feel isolated -- especially in rural areas -- and begin experiencing "not just the blues, but longer periods of the blues," said Joseph Yenerall, a sociologist who has spent the majority of his career examining geriatric mental health.

Research shows that remaining social and active may help prevent mental health problems such as depression in older adults, said Yenerall, who was a longtime sociology professor at Duquesne University in Pittsburgh and served director of school's Graduate Center for Social and Public Policy until he retired last year. Yenerall also studied high suicide rates among older white men, particularly in rural areas in several western states.

About 12 percent of Americans age 65 or older, however, have reported that they "rarely" or "never" receive the social and emotional support they need, according to the CDC's Behavioral Risk Factor Surveillance System. About 13 percent of Pennsylvanians reported the same.

"There is a need for continuing socialization, continued social connections, to work through some of these difficult life circumstances that are more likely to occur among more mature people," Yenerall said, noting that getting involved at places like senior centers, such as Beaver County's Center at the Mall, or with church groups are prescriptions for remaining healthy.

The mind and the body

Reynolds said physical decline and depression also often "travel together," interacting and making each other worse.

"With the increase of disabilities that occur as people age, the risk for developing depression symptoms increases," he said.

On top of other stressors, "you're losing a limb or you're losing your vision because of diabetes, or you're not able to drive now, you have arthritis pain or there's no support from your children because they're all out of state," explained Dr. Grace Huang, director of psychiatric services at Heritage Valley Staunton Clinic.

A 2009 research study funded by the National Institutes of Health found that total health care costs for Medicare participants who had depression and chronic diseases such as diabetes or congestive heart failure were almost double the costs for participants with chronic disease but no depression.

Tod Marion, a geriatric psychologist based in Brighton Township, said older adults with mental health problems and chronic illnesses often become non-compliant with things such as medications. Reynolds added that research has found that older adults with depression also are at risk of developing cognitive disorders, and those with severe mental illness also may have shorter life expectancies.

"Depression can affect heart health and brain health no less than hypertension can affect heart health and brain health," Reynolds said.

The growing numbers of older adults who develop dementia also frequently experience mental health or behavioral problems such as agitation or depression, which Luann Richardson, associate professor in the Robert Morris University School of Nursing and Health Sciences, said can make it difficult for them to safely live on their own, or for family caregivers.

"That's going to be the biggest issue that we're going to face moving forward with our geriatric population," said Richardson, who teaches geropsychiatry in the doctorally prepared nurse practitioner program.

Some nursing homes and facilities are prepared to care for individuals with both physical and mental health conditions, but some aren't, Richardson said. And in some acute cases, older adults have to be hospitalized in psychiatric or behavioral health units.

Marilyn Buchwald, director of psychiatric services for Heritage Valley Health System's inpatient psychiatric unit in Brighton Township, said about 12 percent of people who are admitted to the 32-bed unit each year are age 60 or older.

'How do you get interested in older people?'

Many of the same treatments that work for younger people with mental illnesses also work for older adults, Reynolds said. But there are added considerations that come with age, such as changes to the body and metabolism, which can affect medication interactions and side effects.

"I notice the older that I get it seems like the medications take a toll on you body and it seems like there's more things that take a toll on you," Cervelli said.

Symptoms of mental illness in older adults also can go unrecognized or misdiagnosed as things such as pain or trouble sleeping.

Most providers are exposed to geriatrics during their education, but Huang said specialty training is still important.

"It helps you to be a more effective treatment provider because you can put things in a more appropriate context," she said.

There are few psychiatrists and other mental health professionals being trained in geriatric care, however, Marion and others said. One of the most commonly cited reasons is low Medicare reimbursement rates for services.

"How do you get interested in older people?" Marion asked.

But the work is exciting, he said.

"I really love it because you meet some marvelous people," Marion said. "I see some marvelous role models in terms of how I want to get older ... It can be really rewarding."

A report from the American Geriatrics Society's (AGS) Geriatrics Workforce Policy Studies Center showed that the United States had only about 1,700 board-certified geriatric psychiatrists in 2010, or about 0.9 for every 10,000 people age 75 and older. Pennsylvania's ratio was slightly higher, with 150 geriatric psychiatrists in the state, or about 1.5 for every 10,000 people age 75 or older.

From 1991 to 2011, the American Board of Psychiatry and Neurology issued more than 3,060 certifications for geriatric psychiatry subspecialties, according to AGS, but as of 2012 only about 1,340 certifications remained active.

Based on training numbers and the "silver tsunami" of aging baby boomers such as Cervelli, AGS projects that the United States will have only 0.3 geriatric psychiatrists for every 10,000 people age 75 and older by 2050.

Beaver County is designated by the U.S. Health Resources and Services Administration as a Mental Health Professional Shortage Area, which are areas that have 30,000 or more people for every one psychiatrist -- and that's not just those who specialize in geriatrics. Mental health patients in these areas often face barriers such as long waiting periods for appointments or they must travel to or between offices, according to HRSA.

Staunton Clinic -- and Beaver County in general -- only have a few specialized providers, but Huang said our aging population will only make geriatric specialties more relevant.

"I think particularly for our region, geriatric medicine, geriatric psychiatry, geriatric services is very important, and I think the needs will grow," Huang said.

People also are living longer, Richardson pointed out.

"With the current situation there's a shortage, let alone in the next 10, 20, 30 years," she said.

'It's all the same patient'

One way experts are trying to improve access to mental health services and treatment for older adults is by placing them directly in a primary health care setting, Reynolds explained.

Part of Reynolds' work at Pitt has included using mental health nurse practitioners in doctors' offices, and training general medical nurses and social workers in screening for common mental disorders, although reimbursement for these types of services is still a challenge, he said.

Reynolds and his colleagues at UPMC also are studying the effectiveness of placing medically trained nurses in community mental health centers to help consumers adopt healthy life choices.

The current health care system is not set up to handle all types of care in one place, but Marion said that may be the key.

"You're going to have to have people in the (primary care) office to try to coordinate, manage these kind of folks because they're more willing to come in to their doctor where there's less stigma and so forth, whereas they're not going to come to me as a psychologist," he said.

Marion was director of geriatric services at St. Francis Medical Center in Pittsburgh, which closed in 2002, and he touts the hospital's use of an assessment team for older adult patients, comprised of both mental health professionals and geriatricians.

"It was a great collaborative system, but ... the whole system has changed and you have less collaboration because you have people who are more and more overwhelmed with their own work," he said.

Reynolds and Marion stressed that mental illness is treatable, but ultimately we need a new system of care designed to improve health overall.

"It's all the same patient, and disorders like depression interact with common medical conditions," Reynolds said. "That's the importance of thinking about the whole patient and trying to coordinate services."

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