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Testimony

Statement of the AAGP on Appropriations for the Dept of Health and Human Services

U.S. Senate Committee on Appropriations for the Department of Health and Human Services

3/30/2008

Statement of the American Association for Geriatric Psychiatry to the Subcommittee on Labor, Health and Human Services, and Education, U.S. Senate Committee on Appropriations, on Appropriations for the Department of Health and Human Services

The American Association for Geriatric Psychiatry (AAGP) appreciates this opportunity to present its recommendations on issues related to fiscal year (FY) 2009 appropriations for mental health research and services. AAGP is a professional membership organization dedicated to promoting the mental health and well being of older Americans and improving the care of those with late-life mental disorders. AAGP’s membership consists of approximately 2,000 geriatric psychiatrists as well as other health professionals who focus on the mental health problems faced by senior citizens.

AAGP appreciates the work this Subcommittee has done in recent years in support of funding for research and services in the area of mental health and aging through the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA). Although we generally agree with others in the mental health community about the importance of sustained and adequate Federal funding for mental health research and treatment, AAGP brings a unique perspective to these issues because of the elderly patient population served by our members.

Demographic Projections and the Mental Disorders of Aging
With the baby boom generation nearing retirement, the number of older Americans with mental disorders is certain to increase in the future. By the year 2010, there will be approximately 40 million people in the United States over the age of 65. Over 20 percent of those people will experience mental health problems.

Current and projected economic costs of mental disorders alone are staggering. It is estimated that total costs associated with the care of patients with Alzheimer’s disease is over $100 billion per year in the United States. Psychiatric symptoms (including depression, agitation, and psychotic symptoms) affect 30 to 40 percent of people with Alzheimer’s and are associated with increased hospitalization, nursing home placement, and family burden. These psychiatric symptoms, associated with Alzheimer’s disease, can increase the cost of treating these patients by more than 20 percent.

Depression is another example of a common problem among older persons. Of the approximately 32 million Americans who have attained age 65, about five million suffer from depression, resulting in increased disability, general health care utilization, and increased risk of suicide. Depression is associated with poorer health outcomes and higher health care costs. Co-morbid depression with other medical conditions affects a greater use and cost of medications as well as increased use of health services (e.g., medical outpatient visits, emergency visits, and hospitalizations). For example, individuals with depression are admitted to the emergency room for hypertension, arthritis, and ulcers at nearly twice the rate of those without depression. Those individuals with depression are more likely to be hospitalized for hypertension, arthritis, and ulcers than those without depression. And, those with depression experience almost twice the number of medical visits for hypertension, arthritis and ulcers than those without depression. Finally, the cost of prescriptions and number of prescriptions for hypertension, arthritis, and ulcers were more than twice than those without depression.

Older adults have the highest rate of suicide compared to any other age group. Comprising only 13 percent of the U.S. population, individuals age 65 and older account for 19 percent of all suicides. The suicide rate for those 85 and older is twice the national average. More than half of older persons who commit suicide visited their primary care physician in the prior month – a truly stunning statistic.

The Challenge of Meeting the Mental Health Needs of the Aging Population – Proposal for IOM Study on Mental Health Workforce Needs of Older Americans
On April 14, 2008, the Institute of Medicine (IOM) of the National Academy of Sciences released a study of the readiness of the nation’s healthcare workforce to meet the needs of its aging population. In discussions with AAGP prior to the release of the study, IOM recommended that, because the scope of this study would not provide for in-depth consideration of the mental health workforce needed to meet future needs of the elderly, a complementary study be undertaken to consider specifically this vital area of concern. This complementary study would focus on the mental health professional workforce that will be needed to meet the demands of the aging population in this country. IOM has advised AAGP that $1 million would be needed to undertake this complementary mental health study.

In discussions with AAGP, the senior staff of IOM suggested the following language for inclusion in the LaborHHS Appropriations bill:

The Committee provides $1,000,000 for a study by the Institute of Medicine of the National Academy of Sciences to determine the multi-disciplinary mental health workforce needed to serve older adults. The initiation of this study should be not later than 60 days after the date of enactment of this Act, whereby the Secretary of Health and Human Services shall enter into a contract with the Institute of Medicine to conduct a thorough analysis of the forces that shape the mental health care workforce for older adults, including education, training, modes of practice, and reimbursement.

AAGP strongly urges inclusion of this proposal for funding for an IOM study on mental health workforce needs of older Americans in the FY 2009 Labor HHS Appropriations bill.

National Institute of Mental Health
In his FY 2009 budget, the President again proposed decreased funding for the National Institutes of Health (NIH). This decline in funding would have a devastating impact on the ability of NIH to sustain the ongoing, multi-year research grants that have been initiated in recent years.

AAGP would like to call to the Subcommittee’s attention the fact that, even in the years in which funding was increased for NIH and NIMH, these increases did not always translate into comparable increases in funding that specifically address problems of older adults. Data supplied to AAGP by NIMH indicates that while extramural research grants by NIMH increased 59 percent during the five-year period from FY 1995 through FY 2000 (from $485,140,000 in FY 1995 to $771,765,000 in FY 2000), NIMH grants for aging research increased at less than half that rate: only 27.2 percent during the same period (from $46,989,000 to $59,771,000).

Despite the fact that over the past seven years Congress, through Committee report language, has specifically urged NIMH to increase research grant funding devoted to older adults, this has not occurred. In fact, this Committee’s report accompanying the appropriations bill for FY 2008, stated:

Older Adults - The Committee urges the NIMH to place a stronger emphasis on research on adults over age 65 to reflect the growth in numbers of this population. The Committee requests that the Institute provide data in the fiscal year 2009 congressional budget justifications on the amount of NIMH funding directed toward geriatric mental health research over the past 5 years.

The critical disparity between Federally funded research on mental health and aging and the projected mental health needs of older adults is continuing. If the mental health research budget for older adults is not substantially increased immediately, progress to reduce mental illness among the growing elderly population will be severely compromised. While many different types of mental and behavioral disorders occur in late life, they are not an inevitable part of the aging process, and continued and expanded research holds the promise of improving the mental health and quality of life for older Americans.

Center for Mental Health Services
It is also critical that there be adequate funding for the mental health initiatives under the jurisdiction of the Center for Mental Health Services (CMHS) within SAMHSA. While research is of critical importance to a better future, the patients of today must also receive appropriate treatment for their mental health problems. SAMHSA provides funding to State and local mental health departments, which in turn provide community-based mental health services to Americans of all ages, without regard to the ability to pay. AAGP was pleased that the final budgets for the last five years have included $5 million for evidence-based mental health outreach and treatment to the elderly. AAGP worked with members of this Subcommittee and its House counterpart on this initiative, which is a very important program for addressing the mental health needs of the nation’s senior citizens. However, AAGP is extremely alarmed to see that this program was eliminated in President Bush’s FY 2009 budget proposal. Restoring and increasing this mental health outreach and treatment program must be a top priority, as it is the only Federally funded services program dedicated specifically to the mental health care of older adults.

The greatest challenge for the future of mental health care for older Americans is to bridge the gap between scientific knowledge and clinical practice in the community, and to translate research into patient care. Adequate funding for this geriatric mental health services initiative is essential to disseminate and implement evidence-based practices in routine clinical settings across the states. Consequently, we would urge that the $5 million for mental health outreach and treatment for the elderly included in the CMHS budget for FY 2008 be increased to $20 million for FY 2009. Of that $20 million appropriation, AAGP believes that $10 million should be allocated to a National Evidence-Based Practices Program, which will disseminate and implement evidence-based mental health practices for older persons in usual care settings in the community. This program will provide the foundation for a longer-term national effort that will have a direct effect on the well-being and mental health of older Americans.

Health Resources and Services Administration
Despite growing evidence of the need for more geriatric specialists to care for the nation’s elderly population, a critical shortage persists. AAGP appreciates the work of this Subcommittee in providing for the restoration of funding for the geriatric health professions programs under Title VII of the Public Health Service Act, which was eliminated for FY 2006. The restoration of this program has prevented a devastating impact on physician workforce development over the next decade, with would have dangerous consequences for the growing population of older adults who will need access to appropriate specialized care. The Administration has again proposed eliminating most Title VII programs, including geriatrics. We urge the Subcommittee to fund them at the final FY 2008 level. The geriatric health professions program supports three important initiatives. The Geriatric Faculty Fellowship trains faculty in geriatric medicine, dentistry, and psychiatry. The Geriatric Academic Career Award program encourages newly trained geriatric specialists to move into academic medicine. The Geriatric Education Center (GEC) program provides grants to support collaborative arrangements that provide training in the diagnosis, treatment, and prevention of disease.

Conclusion
Based on AAGP’s assessment of the current need and future challenges of late life mental disorders, we submit the following FY 2009 funding recommendations:

1. An Institute of Medicine study on the future mental health workforce needs for older adults should be funded at $1 million, in accordance with the recommendation of the IOM.

2. The current rate of funding for aging grants at NIMH and CMHS is inadequate and should be increased to at least three times their current funding levels. In addition, the substantial projected increase in mental disorders in our aging population should be reflected in the budget process in terms of dollar amount of grants and absolute number of new grants.

3. To help the country’s elderly access necessary mental health care, previous years’ funding of $5 million for evidence-based mental health outreach and treatment for the elderly within CMHS must be increased to $20 million.

4. Funding for the geriatric health professions program under Title VII of the Public Health Service Act should be continued at no less than FY 2008 levels.

AAGP looks forward to working with the members of this Subcommittee and others in Congress to establish geriatric mental health research and services as a priority at appropriate agencies within the Department of Health and Human Services.

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