Millions of baby boomers will likely face difficulties getting diagnoses and treatment for mental health conditions and substance abuse problems without a major effort to boost the number of health professionals and other service providers who can supply such care as the population ages, according to a report from the Institute of Medicine.

The magnitude of the problem is so great that no single approach or isolated changes in a few federal agencies or programs will address it, the report committee wrote.

The report calls for a redesign of Medicare and Medicaid payment rules to guarantee coverage of counseling, care management and other types of services crucial for treating mental health conditions and substance use problems to ensure clinicians are willing to provide this care.

Organizations that accredit health and social service professional schools and license providers should ensure that all who see older patients — including primary care physicians, nurses, physicians’ assistants and social workers — are able to recognize signs and symptoms of geriatric mental health conditions, neglect and substance misuse and abuse and provide at least basic care, the committee wrote.

Leaders of the U.S. Department of Health and Human Services need to promote national attention to building a workforce of sufficient size that is trained in geriatric mental health and substance abuse care, the authors wrote. They should ensure that all the department’s relevant agencies devote sufficient attention and resources to these conditions.

"There is a conspicuous lack of national attention to ensuring that there is a large enough healthcare workforce trained to care for older adults with mental health and substance use conditions," committee chairman Dan G. Blazer, the J.P. Gibbons Professor of Psychiatry and Behavioral Sciences and vice chairman for faculty development at Duke University in Durham, N.C.,, said in a news release.

"These conditions are relatively common, they can be costly and they can have profound negative impacts on people’s health and wellbeing. This report is a wakeup call that we need to prepare now or our older population and their extended families will suffer the consequences."

Quantifying the problem

The committee conservatively estimated that between 5.6 million and 8 million older Americans — 14% to 20% of the nation’s elderly population — have one or more mental health conditions or problems stemming from substance misuse or abuse. Depressive disorders and dementia-related behavioral and psychiatric symptoms are the most prevalent. Rates of accidental and intentional misuse of prescription medications are increasing. Although the rate of illicit drug use among older individuals is low, studies indicate it will likely increase as the baby-boomer generation ages.

Inattention to older adults’ mental health conditions and substance misuse is associated with higher costs and poorer health outcomes, the authors wrote. For example, older individuals with untreated depression are less likely to properly take medications for diabetes, hypertension and heart disease, and are more likely to require repeated, costly hospital stays.

Training in geriatric care for these problems is necessary, the committee emphasized. Age alters the way people’s bodies metabolize alcohol and medications, increasing the general risk for overdoses; these changes also can cause or intensify alcoholism and addiction. Older adults also are more likely to have physical conditions and impairments in thinking and ability to function that can complicate the detection and treatment of mental health problems and substance misuse or abuse. For example, cognitive impairments can affect an older person’s ability to comply with medication directions.

Medicare and Medicaid payment policies deter effective and efficient care for substance abuse and mental health conditions by limiting which personnel can be reimbursed and which types of services are covered, the committee found. Effective care includes helping patients self-manage their conditions and monitoring to prevent relapses, services that can be provided by a range of trained providers and in a variety of care settings. The Centers for Medicare & Medicaid Services should evaluate alternative payment methods that would better reflect and fund effective services and coordinated, team-based care for mental health and substance abuse, the authors wrote.

Most primary care providers will have frequent contact with older patients, yet their training includes little if any education on geriatric mental health and substance use, the committee noted. Few opportunities exist to specialize in geriatric care for these conditions, and financial incentives and mentor programs are not in place to encourage health professionals to enter or stay in this field.

Health professionals’ training across all disciplines should include competence in these areas, and they should be expected to respond appropriately to signs of mental health or substance use problems within the full extent of their scope of practice, the committee wrote. Congress should appropriate the funds to carry out provisions in the Affordable Care Act that support loan forgiveness and scholarships for individuals who work with or are preparing to work with older adults with mental health conditions or substance use problems.

Resources for HHS programs that have supported or could support geriatric care for mental health and substance abuse have been dwindling and in some cases face elimination, the committee noted. The report urges HHS leaders to ensure each agency provides sufficient attention and funds to grants and other programs to build an adequate workforce able for the provision of this care.

To read an online version of the report, visit http://bit.ly/MYiJHI.