Despite the complex needs of older adults with mental health and substance use conditions (MH/SU), and the unique challenges posed to providers and healthcare systems, MH/SU have received little attention in the shadow of a widely recognized age wave. The recent Institute of Medicine (IOM) report, “The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?” addresses the need to develop a workforce for a rapidly growing population of older adults with these conditions.
For Further Reading
This article was based on findings in the following publications:
Babor T. F., et al. “Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to the Management of Substance Abuse.” Substance Abuse. 2007.
Ciechanowski P., et al. “Community-Integrated Home-Based Depression Treatment in Older Adults.” Journal of the American Medical Association. 2004.
Fried L. P., and Hall W. J. “Leading on behalf of an Aging Society” (PDF). Journal of the American Geriatrics Society. 2008
Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? The National Academies Press, Washington, D.C. 2012.
Madras B. K., et al. “Screening, Brief Interventions, Referral to Treatment (SBIRT) for Illicit Drug and Alcohol Use at Multiple Healthcare Sites: Comparison at Intake and 6 Months Later.” Drug and Alcohol Dependence. 2009.
Mueser K. T., et al. “Randomized Trial of Social Rehabilitation and Integrated Health Care for Older People with Severe Mental Illness.” Journal of Consulting and Clinical Psychology. 2010.
Pratt S.I., et al. “Helping Older People Experience Success: An Integrated Model of Psychosocial Rehabilitation and Health Care Management for Older Adults with Serious Mental Illness.” American Journal of Psychiatric Rehabilitation. 2008.
Schonfeld L., et al. “Screening and Brief Intervention for Substance Misuse among Older Adults: The Florida BRITE Project.” American Journal of Public Health. 2010.
Unutzer J., et al. “Collaborative Care Management of Late-Life Depression in the Primary Care Setting.” Journal of the American Medical Association. 2002.
Unutzer J., et al. “Long-term Cost Effects of Collaborative Care for Late-life Depression-Page 2.” The American Journal of Managed Care. 2008.
A key recommendation of the IOM report is to develop a workforce that extends the relatively small number of physicians and nurses with expertise in geriatrics by implementing evidence-based models of care delivery using an interdisciplinary team approach.
The Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) model is designed to deliver mental health services by embedding a depression care manager in primary care settings where older adults with MH/SU conditions are most likely to seek and receive services. This model of collaborative care incorporates depression screening into the flow of routine primary care practice, along with the care manager, who provides brief problem-solving therapy and works with the primary care provider to monitor treatment outcomes with follow-up assessments and support.
A large multi-site randomized controlled trial showed that IMPACT is associated with significant improvement in depression, while also generating savings of up to $3,300 per person over a four-year period.
The Program to Encourage Active and Rewarding Lives for Seniors (PEARLS) extends these principles into community-based settings by providing a depression care manager who offers problem-solving therapy in community service organizations reaching socially isolated elderly with MH/SU conditions. Results of a randomized control trial of PEARLS also demonstrated improved depressive symptoms, including among a sample of lower-income and racially diverse older adults with mental health concerns.
In contrast, Screening, Brief Intervention and Referral for Treatment (SBIRT) focuses on early intervention and treatment for persons who have substance use disorders. This model provides screening, brief interventions and referral to specialty treatment.
During a six-month period across multiple sites, SBIRT demonstrated significant decreases in alcohol use disorders and illicit drug use, with improvements in self-reported measures including health and mental health. This model has been adapted for use in elderly populations and includes a focus on at-risk drinking and medication misuse.
Finally, Helping Older People Experience Success (HOPES) targets older adults with serious mental illness (schizophrenia, bipolar disorder, and chronic depression associated with poor functioning). HOPES consists of an integrated psychosocial skills training and health management program designed to improve independent functioning and reduce the medical needs of older adults with serious mental illness. A multi-site randomized controlled trial found HOPES is associated with significant long-term improvements in community living skills, social skills, functioning, psychiatric symptoms, self-efficacy, and preventive healthcare compared to usual care.
IMPACT, PEARLS, SBIRT and HOPES, along with other evidence-based models featured in Table 1, span different populations of older adults with different MH/SU conditions, across diverse settings and provider types. By using an interdisciplinary team approach emphasizing care coordination and practical skills, these programs could help develop a workforce to address the rapidly growing population of older adults with MH/SU disorders over the coming decades.
Table 1. Characteristics of selected evidence-based geriatric mental health and substance use models
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Source: Table adapted from the 2012 IOM Report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?
PRISME-E—Primary Care Research in Substance Abuse and Mental Health for the Elderly
PATCH—Psychogeriatric Assessment and Treatment in City Housing
WRAP—Wellness Recovery Action Plan
PREVENT—Providing Resources Early to Vulnerable Elders Needing Treatment
Stephen J. Bartels, M.D., M.S., is professor of Psychiatry, of Community and Family Medicine at the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H. John A. Naslund is a graduate student at The Dartmouth Institute for Health Policy and Clinical Practice. His research interests include aging, chronic disease self-management, and mobile technology-based health interventions.
This article is brought to you by the Editorial Committee of ASA’s Mental Health & Aging Network (MHAN)
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