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Testimony

FY 2012 Appropriations for Mental Health Research and Services (U.S. Senate)

Subcommittee on Labor, Health and Human Services, and Education, U.S. Senate Committee on Appropriations

American Association for Geriatric Psychiatry

4/11/2011

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 FY 2012 Appropriations for the Department of Health and Human Services

The American Association for Geriatric Psychiatry (AAGP) appreciates this opportunity to comment on issues related to fiscal year (FY) 2012 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. AAGPís membership consists of geriatric psychiatrists as well as other health professionals who focus on the mental health problems faced by aging adults. 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
The aging of the baby boomer generation will result in an increase in the proportion of persons over 65 from 12.7 percent currently to 20 percent in 2030, with the fastest growing segment of the population consisting of age 85 and older. During the same period, the number of older adults with major psychiatric illnesses will more than double, from an estimated 7 million to 15 million individuals, meeting or exceeding the number of consumers in discrete, younger age groups.

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, todayís patients must also receive appropriate treatment for their mental health problems.

Evidence-based Mental Health Outreach and Treatment for the Elderly
AAGP was pleased that the final budgets for the last nine five years have included $5 million for evidence-based mental health outreach and treatment to the elderly, the only Federally funded services program dedicated specifically to the mental health care of older adults. AAGP is concerned that this program was eliminated in the Presidentís FY 2012 budget proposal. It is critical that SAMHSA and CMHS ensure that, as they design programs to promote prevention and recovery from mental illness, the senior citizen cohort not be ignored. AAGP asks the Committee to restore the funding for this critical program as well as ensure that all of CMHSís programs assure a life-span approach by specifically including the older adult population as a targeted population.

Centers of Excellence for Depressive and Bipolar Disorders
PPACA also included authorization for a new national network of centers of excellence for depressive and bipolar disorders, which will enhance the coordination and integration of physical, mental and social care that are critical to the identification and treatment of depression and other mental disorders across the lifespan. The work of these centers will help to disseminate and implement evidence-based practices in clinical settings throughout the country. AAGP strongly supports funding for the centers authorized by this legislation and is disappointed that the Administration has not recommended funding them. With respect to older adults, these centers would be able to focus on new models of care that integrate evidenced-based depression care into real world primary care and home care to improve the outcomes; specific combinations of medications and talk therapy that successfully treat depression and prevent relapse in older adults; specific clinical and biological factors that link depression and risk of Alzheimer's disease in some older depressed patients; and prevention of depression in older people at risk. AAGP recommends that these centers be funded at $10 million for FY 2012.

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 nationís 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. AAGP is deeply grateful to this subcommittee and its House counterpart for providing, in the appropriations bill for FY 2010, funding for a follow-up study of the current and projected mental and behavioral healthcare needs for aging Americans. This study, which is now underway, will complement the 2008 IOM study in providing in-depth consideration of the mental health needs of geriatric and ethnic minority populations that were precluded by the broad scope of the earlier one.

Virtually all health care 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 nationís elderly, foretells a crisis in health care that will impact older adults and their families nationwide.

Already, there are programs administered by the Bureau of Health Professions in the HHS Health Resources and Services Administration (HRSA) administers that are aimed to help to assure adequate numbers of health care practitioners for the nationís geriatric population, especially in underserved areas. These are the only federal programs that seek to increase the number of faculty with geriatrics expertise in a variety of disciplines, and the breadth of the programs has been strengthened by provisions included in the Patient Protection and Affordable Care Act (PPACA).

The geriatric health professions program supports these important initiatives:

- The Geriatric Education Center (GEC) program provides interdisciplinary training for health care professionals in assessment, chronic disease syndromes, care planning, emergency preparedness, and cultural competence unique to older Americans. PPACA authorizes $10.8 million in supplemental grants for the GEC Program to support training in geriatrics, chronic care management, and long-term care for faculty in a broad array of health professions schools, as well as direct care workers and family caregivers. GECs receiving these grants are required to develop and include material on depression and other mental disorders common among older adults, medication safety issues for older adults, and management of the psychological and behavioral aspects of dementia in all appropriate training courses.

- 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 geriatric specialists in junior faculty positions who are committed to teaching geriatrics in professional schools. PPACA expands the disciplines eligible for the awards. GACA recipients are required to provide training in clinical geriatrics, including the training of interdisciplinary teams of health care professionals.

- PPACA authorized a new Geriatric Career Incentive Awards Program in Title VIII of the Public Health Service Act for grants to foster great interest among a variety of health professionals in entering the field of geriatrics, long-term care, and chronic care management. This program was authorized for $10 million over three years.

- A new program, authorized by PPACA at $10 million for three years, will provide advanced training opportunities for direct care workers in the field of geriatrics, long term-care or chronic care management.

AAGP strongly supports increased funding for the existing programs, particularly as the disciplines included have been expanded, and funding to fully authorized levels for the new programs.

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. 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.

AAGP believes that it is critical that NIH begin to invest increased funding in future evidence-based treatments for our nationís elders. 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.

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 nationís mentally ill elderly. This is a critical public health obligation of the nationís 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.

Study on NIH Funding for Mental Disorders among Older Adults
As little emphasis has been placed on the development of new treatments for geriatric mental disorders, AAGP encourages 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. NIH is already working 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 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.

Conclusion
AAGP recommends:
o Increased funding for the geriatric health professions education programs under Title VII of the Public Health Service Act and full funding for new programs authorized by the PPACA;
o Funding to support clinical trials involving older adults;
o A GAO study on spending by NIH on conditions and illnesses related to the mental health of older individuals;
o $5 million in funding to continue evidence-based geriatric mental health outreach and treatment programs at CMHS;
o $10 million in funding for Centers of Excellence for Depressive and Bipolar Disorders.

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