The Institute of Medicine (now the National Academy of Medicine) issued a report in 2012, “The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?” that said 14 to 20 percent of U.S. adults over age 65 have one or more mental health or substance use conditions. That’s about 8 million people. Yet a number of studies also indicate that mental illness in older adults is underrecognized and underdiagnosed.
For instance, a telephone survey of nearly 10,000 adult households, published in 2003 in the American Journal of Geriatric Psychiatry, found that half of adults over age 65 with a probable mental illness were significantly less likely to be receiving any mental health treatment than younger adults. Of those, only 7 percent had used specialty mental health care.
“Indeed, compared with younger adults and middle-aged adults, adults over age 65 were much less likely to be asked by their primary care physician if they felt tense or anxious and were much less likely to be referred by their primary care physician for mental health specialty care,” says Dr. Susan W. Lehmann, clinical director of the division of geriatric psychiatry and neuropsychiatry and director of the Geriatric Psychiatry Day Hospital at the Johns Hopkins University School of Medicine. A more recent study of seniors receiving home health services found that 23 percent screened positive for depression, yet less than 40 percent of those people were receiving treatment for depression, she says.
[See: Am I Just Sad — or Actually Depressed?]
Diagnosis Is Challenging
There are a number of reasons why mental illness is underdiagnosed among seniors. An interesting finding of the telephone survey, Lehman says, was that older adults themselves were much less likely to perceive a need for mental health care than younger adults, so they may be less likely to bring up concerns with their primary care provider.
Ageism and perceived stigma about mental health care may play a role as well. “Many older adults and their family members may incorrectly believe that depression is normal with aging,” she says. “Given the time constraints of outpatient medical appointments, the primary care provider may feel challenged to review these ongoing health conditions in a short time frame and may not feel there is time to discuss mental health concerns unless the patient brings it up.”
There also may be confounding issues that confuse clinicians. “Older people grew up in an era when talking about a psychiatric issue was certainly frowned upon, so there may be a generational issue,” says Dr. Philip R. Muskin, a professor of psychiatry at Columbia University Medical Center and a member of the American Psychiatric Association’s Scientific Program Committee. Elderly patients also may ascribe their moods to physical impairments or other illnesses. And many of the symtoms of depression and anxiety — poor sleep, low appetite, memory and concentration problems — are also markers of simply being older.
“We can confuse complaining about sleeping and appetite that may not be depression,” Muskin says. “Is that memory loss from depression or mild cognitive impairment? All of that makes it tougher to make the diagnosis. If a young person is not sleeping, has no appetite, no energy, the first thing I think of is depression. An 85-year-old with those same things, depression is not going to be high on my list.” Lehman agrees: “Too often, changes in mood, interest, activity level and personality are incorrectly attributed to aging , and the possibility of a mental illness is not considered.”
[See: How to Find the Best Mental Health Professional for You.]
Another confounding factor: Many older adults have multiple health problems requiring multiple medications, which can affect mood. “It can be difficult to tease out depression and other mental health concerns from coexisting medical conditions or medications that might cause symptoms mimicking depression and other mental health symptoms,” Lehman says.
Treatment Is Effective
Lehman finds all of these reasons worrisome because mental illness in older adults is treatable when it’s discovered. “With appropriate and effective treatment, quality of life and overall functioning is improved and maintained,” she says.
The same treatments, both medications and talk therapies, that are used for younger adults with mental illness are also effective for seniors. However, older adults may be more prone to certain medication side effects, and they metabolize the medications differently than younger adults. “The elderly are more vulnerable to [side effects] like balance issues and gastrointestinal issues,” Muskin says. “That can limit the speed with which you raise the dosage, so it takes longer for the meds to work.”
[Read: What Are the Secrets to Aging Well?]
Family and loved ones have an important role to play in encouraging a senior who may be experiencing symptoms of mental illness to receive an appropriate evaluation, Lehman says. “Speaking with the senior’s primary care provider is often the right first step,” she explains. If specialty care is recommended, loved ones can help ensure that the individual follows through with the appointment and recommended treatment.
The worst thing to do, Muskin says, is nothing. “If you think it, don’t let it slide,” he says. “Bring it up. When grandma says go jump in the lake, bite your tongue and encourage her to see her doctor. It’s hard to do, but once done, it may really save a life. It is treatable, whatever it might be.”
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Why Mental Illness Is So Hard to Spot in Seniors originally appeared on usnews.com
