It's Never Too Late for Good Mental Health

~ by Carol Vartuli

It seems counterintuitive, but as the aging population increases, the number of physicians dedicated to geriatric medicine in the U.S. is decreasing. This includes the psychiatrists who have expertise in treating older citizens.

The American Association for Geriatric Psychiatry calls this shortfall a crisis. “The proportion of the population over age 65 will increase from 12.4% of the U.S. population in 2000 to 20% by the year 2030 (U.S. Census Bureau). During that period, the number of older adults with mental illness is expected to double to 15 million.”

Depression is a common mental health disorder, from people’s teen years through adulthood. Elder individuals are typically happier with their lives than their younger counterparts, despite age-related physical limitations or illness. Depression is not a normal part of aging. Yet, late-onset depression affects more than two million Americans over age 65.

General practitioners may not recognize its symptoms, though, because they often attribute grumpiness and irritability, sleep problems, and memory lapses to an older person’s health issues, or medications.

What Causes Later-Life Depression?

The most common causes of later-life depression are:

• Genetics: Older adults who have had relatives with depression are more apt to develop it themselves
• Personal history: People who experienced depression earlier in life are at higher risk
• Physical illness: Heart disease, cancer, arthritis, diabetes, etc. may trigger late-onset depression, and depression can exacerbate those illnesses
• Brain chemistry: Some people have imbalances in the brain’s neurotransmitters--serotonin and dopamine
• Environment: Older adults may experience unique stress that comes with aging: complicated grief, social isolation, physical disabilities, financial struggles, and juggling multiple medications

According to the National Institutes of Health, the most common depressive disorders are: 1) major depression, which may occur as an episode only once in a lifetime, or may involve several episodes over time. Its symptoms are severe and interfere with the ability to work, sleep, study, eat, and enjoy life; 2) persistent depressive disorder, a depressed mood that lasts at least two years and includes episodes of major depression, and periods of less severe symptoms; and 3) vascular depression, which occurs when changes in the brain and body--such as restricted blood flow-- cause depression for the first time in an older adult. 

What is the Impact of Fewer Psychiatrists?

A shortage of practicing psychiatrists in general, and geriatric psychiatrists specifically, is a reality. A 2018 report by physician recruitment firm, Merritt Hawkins, showed there are 30,451 practicing psychiatrists in the United States, an average of only nine per 100,000 people. They are not evenly distributed, however, leaving 60 percent of U.S. counties with none.

Coupled with the fact that 45 percent of psychiatrists do not accept Medicaid or private health insurance (JAMA Psychiatry, 2014), the dearth of psychiatrists also leads to longer wait times, shorter visits, and longer-spaced appointments for medication monitoring.

Extending Mental Health Care’s Reach

Fortunately, a growing community of trained psychiatric professionals, along with technology, is helping to fill the gap.

Psychologists, because they are not M.D.s like psychiatrists, do not traditionally prescribe and monitor medication for depression.  But they are highly skilled in psychotherapy, and part of a network that includes psychiatrists, who can prescribe and monitor medication several times a year for patients in the psychologist’s care. Many late-onset cases of depression do not require medication and respond well with psychotherapy alone.

Psychiatric-mental health nurse practitioners (PMHNP) provide care “similar to that of psychiatrists, that is high quality and leads to positive outcomes” (American Journal of Preventive Medicine 2018). They are registered nurses, further trained in mental health, to assess patients’ mental health, diagnose mental health disorders, prescribe medication, and provide therapeutic treatments, like psychotherapy.

Physician Assistants (PAs) in psychiatry, working under the supervision of a psychiatrist or other physician, can provide mental health assessments, make diagnoses and rule out underlying medical problems that could be behind symptoms, prescribe medications, order lab tests, and make referrals to other medical practitioners.

In addition, technology is making it possible for more people, in more places, to get care faster and more conveniently. Telepsychiatry enables you to “see” a psychiatrist or other mental health professional for a psychiatric evaluation and treatment plan.

Most states already require private insurers to cover telepsychiatry in some way, although Medicare subscribers may only be covered for telehealth while in a medical office or facility.

How Can You Help?

Perhaps the most confounding aspect of depression is the affected person’s reluctance to use the word “depressed.” In earlier generations, mental health problems cast a stigmatizing shadow. The mere thought of being confined in a state “mental institution” undoubtedly kept people from seeking professional help. Today, that haunting association may still present a challenge to seeking help.

Untreated chronic depression in older adults can have ongoing side effects. Grandma prefers to be “left alone,” and has withdrawn from activities and social contacts she once enjoyed. She’s irritable and fatigued, and her flagging appetite is melting pounds off her already slight frame.  As her loved one, you likely feel helpless and frustrated when she brushes off your offers of help.

Severe depression can prevent the patient from adequately verbalizing the distress. Physicians or caregivers may mistake symptoms of late-onset depression for dementia. Family members are often the best-equipped to recognize what is not normal sadness in a loved one.

So, what can you do?

• Educate yourself, because the more you understand about later-life depression, the better advocate you can be for your parent, uncle, or friend.
• Make an appointment with his or her doctor, and be there to tell the doctor what you see going on with your loved one. The doctor can perform some pre-assessments to help determine treatment options.
• Reassure your loved one that you will be by her side through the experience. Sometimes, an in-patient treatment center that specializes in elder care is the best option, particularly if medication management will be involved. Outpatient group, individual, and family therapy may also be recommended.

Older individuals don’t have to bear the weight of depression, or other mental illness, alone. Life at any age deserves its measure of contentment and joy.

The information in the above article is not intended nor implied to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.