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The Emerging, Invisible Gray Crisis

by Ron Manderscheid, Ph.D.

Aging Population
Anyone who has worked in behavioral health knows that older adults are practically invisible. At the national level, they are rarely discussed; state and county agencies lack a focus on this population; and most provider organizations simply do not serve them. Historically, the field of mental health has been very adult oriented, with a more recent emphasis on children. Older persons have never received their fair level of attention.

Today we are witnessing the early phases of an invisible but emerging gray crisis surrounding the mental health of older adults. This brief commentary describes the nature of the crisis and some of the important steps that must be taken to address it.

The National Picture for Older Adults
U.S. Census Bureau data show some astonishing trends for older adults. Between 2010 and 2030, the population of individuals age 65 and up is expected to grow from 40.2 to 72.1 million. At the same time, this segment of the public is likely to expand from 13.1 percent to 19.3 percent of our total population. If we look as far as 2060, the total number of older adults is likely to grow to 98 million—23.5 percent of our population (Colby & Ortman, 2014). Thus, in less than 50 years, one in four Americans will be an older adult.

Extensive mental health epidemiology is not available for the older adult population. However, two important studies shed some light on this topic. The first (Byers et al., 2010) found 12-month prevalence rates for the following conditions among people age 55 and over: mood disorders (4.9 percent), anxiety disorders (11.6 percent), and comorbid mood and anxiety disorders (2.8 percent). The data come from the National Comorbidity Survey Replication conducted between 2001 and 2003.

The second study of people in the same age group, conducted by Reynolds et al. in 2015, found similar 12-month rates for mood disorders (6.8 percent) and anxiety disorders (11.4 percent). It also added 12-month prevalence rates for substance use disorders (3.8 percent) and personality disorders (14.5 percent). This study was based on Wave 2 of the 2001–02 National Epidemiologic Survey on Alcohol and Related Conditions.

Both studies noted that prevalence rates decreased with increasing age and found higher rates of mood and anxiety disorders among women. The Reynolds et al. study documented higher rates of substance use and personality disorders among men.

But this is only one part of the story. In another study conducted by Byers et al., results showed 71.3 percent of older adults with a mood or anxiety disorder did not use any mental health services. According to a 2008 Issue Brief from the Centers for Disease Control and Prevention, 12.2 percent of people 65 and over rarely or never receive the social or emotional support they need.

If we project these findings to the 2030 population of adults 65 and older using 12-month prevalence, mood disorders would affect about 3.6 million, anxiety disorders would affect 7.9 million, substance use disorders would be a problem for 2.9 million, and personality disorders would affect 10.1 million people. Ignoring comorbidities, these four groups could total 24.5 million (34 percent) by 2030. Clearly, we will have a substantial mental health problem in the not-so-distant future. We cannot continue to disregard older adults or their mental health.

Planning for Action
The first step in addressing this emerging crisis is to develop a plan to improve the response for older adults who struggle with behavioral health conditions or addiction. Such a plan should include the following actions:

Monitoring Population Characteristics and Insurance Coverage. One cannot overstate the need for national socioeconomic monitoring of the older adult population. Where do they live? What access do they have to family supports, community supports, and health care of all types, including behavioral health care? How many are staying in the workforce into their 70s and 80s? How well does Medicare and Medicare supplemental insurance cover health service needs? Who cannot afford their related insurance premiums? There are many other questions and answers to consider, but such data should form the basis of our national planning.

Implementing Better and Continuous Population Epidemiology. The studies cited above were conducted in the early 2000s. For practical planning purposes, these data are far too old. We must have more recent information on disorders, service use, and the reasons behind underuse of services. Because of the dynamic nature of the older adult population, it will be important to collect this kind of data on a recurring basis.

Developing Appropriate Services for Older Adults. Services appropriate for a 40-year-old won't always work for someone who is 75. Factors such as the service site (office or home), physical infirmities (hearing difficulties, impaired focus), family situation (no close relatives nearby), and other personal circumstances (e.g., chronic disabilities) may loom large in service access, uptake, and outcomes for older adults. Hence, research and development work is urgently needed to implement behavioral health service programs that are fitting and effective for older adults. Can current services be adapted? What new services are necessary?

Fostering a Workforce Committed to This Population. Behavioral health care is already in the midst of a workforce crisis, with too few providers to address burgeoning service needs. Creative thinking will be essential to design new university training programs and motivate students to enter the field of gerontological behavioral health care. These providers must be trained to work in a range of new settings (e.g., integrated care), using new approaches (e.g., community interventions). A potential pool of behavioral health providers are baby boomers, who are now reaching retirement age and could be enlisted to serve older adults.

Mobilizing Related Human Resources. Perhaps the easiest group to mobilize is older adult peer supporters. Relationships would not only benefit from great mutuality, but also from the social support they can provide to reduce feelings of isolation and loneliness. Other groups to consider are teens, who could pay friendly visits; neighbors, who could assist with household chores and buying groceries; and community health workers, who could be specially trained to work with older adults.

Next Steps
The need to mobilize a national plan for providing high-quality behavioral health services to older adults is urgent, and the rewards are many. We can do much to change the atmosphere for the aging population today. And our older selves will thank us.

Dr. Manderscheid is the executive director of the National Association of County Behavioral Health and Developmental Disability Directors and the National Association for Rural Mental Health. He is an adjunct professor at Johns Hopkins University.

Byers, A. L., Arean, P. A., & Yaffe, K. (2012). Low use of mental health services among older adults with mood and anxiety disorders. Psychiatric Services, 63(1), 66–72.

Byers, A. L., Yaffe, K., Covinsky, K. E., Friedman, M. B., & Bruce, M. L. (2010). High occurrence of mood and anxiety disorders among older adults: The national comorbidity survey replication. Archives of General Psychiatry, 67(5), 489–496.

Centers for Disease Control and Prevention and National Association of Chronic Disease Directors (NACDD). (2008). The state of mental health and aging in America: What do the data tell us? Issue Brief 1. Atlanta, Ga.: NACDD.

Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S. population: 2014 to 2060. Current Population Reports, P25–1143. Washington, D.C: U.S. Census Bureau.

Reynolds, K., Pietrzak, R. H., El–Gabalawy, R., Mackenzie, C. S., and Sareen, J. (2015). Prevalence of psychiatric disorders in U.S. older adults: Findings from a nationally representative survey. World Psychiatry, 14(1), 74–81.
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