FY 2010 Appropriations for Mental Health Research and Services (Written Testimony)
Testimony of the American Association for Geriatric Psychiatry on March 18, 2009
Before the U.S. House Appropriations Subcommittee on Labor, Health and Human Services, and Education
Board Member Paul D. Kerwin, MD
The American Association for Geriatric Psychiatry (AAGP) appreciates this opportunity to testify before the Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies on issues related to fiscal year (FY) 2010 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 aging adults.
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 and the Substance Abuse and Mental Health Services Administration. 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.
A National Health Crisis: 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. The number of ethnic and minority elders in the population is increasing as well, with the number of African American elders doubling and a tripling of the number of Latinos.
The cost of treating mental disorders can be 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 crippling family burden. These psychiatric symptoms, associated with Alzheimer’s disease, can increase the cost of treating these patients by more than 20 percent. However, these costs pale when compared to the costs of not treating mental disorders including lost work time, co-morbid illness, and increased nursing home utilization. It is also important to note the added burden, financial and emotional, on family caregivers, as the nation’s informal caregiving system is already under tremendous strain and will require more support in the years to come.
Depression is another example of a common diagnosis 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 risk of suicide. Depression is associated with poorer health outcomes and higher health care costs. Those with depression are more likely to be hospitalized and experience almost twice the number of medical visits than those without depression. Finally, the cost and number of prescriptions for this group were more than twice than those without depression.
Older adults also have the highest rate of suicide compared to any other age group. 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.
Preparing a Workforce to meet the Mental Health Needs of the Aging Population
In 2008, the Institute of Medicine (IOM) released a study of the readiness of the nation’s healthcare workforce to meet the needs of its aging population. The Re-tooling for an Aging America: Building the Health Care Workforce called for immediate investments in preparing our health care system to care for older Americans and their families. Virtually all healthcare providers need to be fully prepared to manage the common medical and mental health problems of old age. In addition, the number of geriatric health specialists, including mental health providers, needs to be increased both to provide care for those older adults with the most complex issues and to train the rest of the workforce in the common medical and mental health problems of old age. The small numbers of specialists in geriatric mental health, combined with increases in life expectancy and the growing population of the nation’s elderly, foretells a crisis in health care that will impact older adults and their families nationwide. Unless changes are made now, older Americans will face long waits, decreased choice, and suboptimal care. AAGP is part of the new Eldercare Workforce Alliance, a national organization of 25 organizations representing consumers, family caregivers, the direct-care workforce, and health care professionals, that has been formed to proposed practical solutions to strengthen our eldercare workforce and improve the quality of care.
In order to implement the IOM report, AAGP believes that there are several critical issues that this Committee should address:
IOM Study on Geriatric Mental Health Workforce
AAGP believes that the broad scope of the 2008 IOM study, while meeting a crucial need for information on the many issues regarding the health workforce for older adults, precluded the in-depth consideration of the workforce needed for treating mental illness. The study should be followed by a complementary study focused on the specific challenges in the geriatric mental health field. This study should follow up the general IOM study in two specific ways: it should examine the access and workforce barriers unique to geriatric mental healthcare services; and, in discussing possible alternative models of geriatric service delivery (such as medical homes, PACE programs, collaborative care models like those demonstrated in the IMPACT and PROSPECT studies), it should articulate the importance of integrating geriatric mental health services as intrinsic components. “The Retooling the Health Care Workforce for an Aging America Act,” S. 245/H.R. 46, contains a provision mandating this additional study.
In discussions with AAGP, the senior staff of IOM suggested the following language for inclusion in the Labor/HHS 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.
Title VII Geriatric Health Professions Education Programs
The Bureau of Health Professions in the HHS Health Resources and Services Administration (HRSA) administers programs aimed to help to assure adequate numbers of health care practitioners for the nation’s geriatric population, especially in underserved areas.
The geriatric health professions program supports three important initiatives. The Geriatric Education Center (GEC) Program, within defined geographic areas, provides interdisciplinary training for health care professionals in assessment, chronic disease syndromes, care planning, emergency preparedness, and cultural competence unique to older Americans.
The Geriatric Training for Physicians, Dentists, and Behavioral and Mental Health Professionals (GTPD Program) provides fellows with exposure to older adult patients in various levels of wellness and functioning and from a range of socioeconomic and racial/ethnic backgrounds.
The Geriatric Academic Career Awards (GACA) support the academic career development of geriatricians in junior faculty positions who are committed to teaching geriatrics in medical schools across the country. GACA recipients are required to provide training in clinical geriatrics, including the training of interdisciplinary teams of health care professionals. AAGP supports increased funding for these programs as a means to increase geriatric specialist health care providers. Specifically AAGP supports:
· Expanding GECs to include at least one center in each of the 50 states and more than one in states that cover large geographic areas or have large populations;
· Expanding GEC grants to offer mini-fellowships in geriatrics to faculty members of medical schools and other health professions schools, including psychology, pharmacy, nursing, social work, dentistry, and public health;
· Enhancing GACA awards to support and retain clinician educators from a variety of disciplines as they advance in their careers; and
· Providing full funding for the National Center for Workforce Analysis to analyze current and projected needs for health care professionals and paraprofessionals in the long-term care sector.
National Institutes of Health (NIH) and National Institute of Mental Health (NIMH)
With the graying of the population, mental disorders of aging represent a growing crisis that will require a greater investment in research to understand age-related brain disorders and to develop new approaches to prevention and treatment. 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 the NIMH, these increases did not always translate into comparable increases in funding that specifically address problems of older adults. For instance, according to figures provided by NIMH, NIMH total aging research amounts decreased from $106,090,000 in 2002 to $85,164,000 in 2006 (dollars in thousands: $106,090 in 2002, $100,055 in 2003, $97,418 in 2004, $91,686 in 2005, $85,164 in 2006).
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. This trend must be immediately reversed to ensure that our next generation of elders is able to access effective treatment for mental illness. Federal funding of research must be broad-based and should include basic, translational, clinical, and health services research on mental disorders in late life.
As the NIMH utilizes the new funding from “The American Recovery and Reinvestment Act of 2009,” it is necessary that a portion of those funds be used to invest in the future evidence- based treatments for our nation’s elders. Beginning in FY 2010, annual increases of funds targeted for geriatric mental health research at NIH should be used to: (1) identify the causes of age-related brain and mental disorders to prevent mental disorders before they devastate lives; (2) speed the search for effective treatments and efficient methods of treatment delivery; and (3) improve the quality of life for older adults with mental disorders. Improving the treatment of late-life mental health problems will benefit not only the elderly, but also their children, whose lives are often profoundly affected. Caregiving itself is an enormous drain on the financial security and health of family members, many of whom become depressed or experience exacerbations of their own medical problems and disabilities.
Participation of Older Adults in Clinical Trials
Federal approval for most new drugs is based on research demonstrating safety and efficacy in young and middle-aged adults. These studies typically exclude people who are old, who have more than one health problem, or who take multiple medications. As the population ages, that is the very profile of many people who seek treatment. Thus, there is little available scientific information on the safety of drugs approved by the Food and Drug Administration (FDA) in substantial numbers of older adults who are likely to take those drugs. Pivotal regulatory trials never address the special efficacy and safety concerns that arise specifically in the care of the nation’s mentally ill elderly. This is a critical public health obligation of the nation’s health agencies. Just as the FDA has begun to require inclusion of children in appropriate studies, the agency should work closely with the geriatric research community, health care consumers, pharmaceutical manufacturers, and other stakeholders to develop innovative, fair mechanisms to encourage the inclusion of older adults in clinical trials. Clinical research must also include elders from diverse ethnic and cultural groups. In addition, AAGP urges that Federal funds be made available each year for support of clinical trials involving older adults.
As little emphasis has been placed on the development of new treatments for geriatric mental disorders, AAGP would encourage the NIH to promote the development of new medications specifically targeted at brain-based mental disorders of the elderly. AAGP urges this Committee to request a GAO study on spending by NIH on conditions and illnesses related to the mental health of older individuals. The NIH has already undertaken, in its Blueprint for Neuroscience Research, an endeavor to enhance cooperative activities among NIH Institutes and Centers that support research on the nervous system. A GAO study of the work being done by these 16 institutes in areas that predominately involve older adults could provide crucial insights into possible new areas of cooperative research, which in turn will lead to advances in prevention and treatment for these devastating illnesses.
Development of New Investigators
Investments in the development of new investigators who initiated peer-reviewed research ensure that federal taxpayers’ dollars support the growth and progress of basic and clinical neuroscience. Without the entry of new investigators, the progress of our scientific enterprise is threatened. Federal support of programs that provide incentives for young scientists to pursue careers has significantly eroded in the past decade, to the point where medical and graduate students are actively discouraged from pursuing academic research careers. To recruit and maintain a highly talented scientific investigator workforce, the Federal government must take the lead in providing incentives and support.
Center for Mental Health Services
It is critical that there be adequate funding for the mental health initiatives under the jurisdiction of the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (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. AAGP was pleased that the final SAMHSA budgets for the last eight 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 Senate counterpart on this initiative, and urges an increase in funding from $5 million to $20 million for this essential program to disseminate and implement evidence-based practices in routine clinical settings across the states. 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.
· An IOM study on the geriatric mental health workforce to examine the access and workforce barriers unique to geriatric mental healthcare services and, to articulate the importance of integrating geriatric mental health services as intrinsic components;
· Increased funding for the geriatric health professions education programs under Title VII of the Public Health Service Act;
· A GAO study on spending by NIH on conditions and illnesses related to the mental health of older individuals.
· Increased funding for evidence-based geriatric mental health outreach and treatment programs at CMHS.