public policy & aging report

Summer 2013 The Geriatric Mental Health Challenge Volume 23, Number 3

Public Policy & Aging Report®

Continued on page 30 Continued on page 3

BackgroundPursuant to the Community Mental Health Act of 1963,

state psychiatric hospital residents were discharged en masseand moved back home into their communities. In many cases,residents who were over 65 had no home or family to returnto, and the newly organized system of community mentalhealth centers was poorly prepared to treat geriatric patients.As such, many of these older adults were transferred intonursing facilities, often without being provided necessaryspecialized services (Committee of Nursing Home Regulation,1986; Kahn, 1975). The Institute of Medicine (IOM) defined the unexpected increase in nursing facility residents withpsychiatric conditions and the corresponding lack ofspecialized care as a public-health-policy problem (Institute of Medicine [IOM], 1986). In response, the United StatesCongress enacted the Nursing Home Reform Act (NHRA) as part of the Omnibus Budget Reconciliation Act of 1987.

The goal of the NHRA was to reduce the use of physicalrestraints and medications as the primary form of care forresidents with psychiatric conditions and to increase the use of nonpharmacological therapeutic services (Molinari et al., 2011). To reach this goal, the NHRA required all states to implement the Pre-Admission Screening and AnnualResident Review (PASRR), a process of care designed toprevent individuals with serious psychiatric conditionsfrom being placed in a nursing facility that could not providespecialized services (Timmel, 2005).

Operationally, PASRR consists of two steps, and anylicensed nursing facility that receives Medicaid reimbursements

Perspectives on the Pre-Admission Screening

and Annual Resident ReviewProcess: Why Can’t This Program Just Grow Up?Jane Hudson • Lauren Erickson • Scott Lyon

Jayna Grauerholz • Jean Herrity

The Widespread Deployment of Integrated Models of Care

Brian Kaskie

The number of Americans over the age of 65 is projectedto grow from 40.3 million to 72.1 million between now and2030, and the proportion of older individuals is expected to increase from one out of eight to one out of every sixpeople living in the United States (U.S. Census Bureau, 2011).This unprecedented expansion of the aging populationpresents several challenges, among them the rising numberof older individuals with psychiatric conditions. Each year,approximately 20 percent of the older American populationexperiences a psychiatric condition that could be treated bya behavioral health care specialist (Karel, Gatz, & Smyer, 2012;U.S. Department of Health and Human Services, 1999).Although depression, anxiety, phobias, and other conditionscharacterized by acute distress are the most common amongpeople over 65, other typical disorders include serious andpersistent mental illnesses—such as schizophrenia, paranoia,bipolar disorder, and major depression—and neurocognitivedisorders, such as dementia and delirium. In all, the Instituteof Medicine (2012) identified 27 different psychiatricconditions that can have a substantial impact on an olderadult’s affect, cognition, and overall functioning; 15 of theseconditions constitute diagnosable disorders, and theremaining 12 reflect symptom clusters that often warrantspecialty behavioral health care.

Based on applying prevalence rates to current populationestimates, as many as 8.6 million people over 65 are thought to be experiencing a psychiatric condition. As the U.S.population continues to grow older, the number of olderadults experiencing a psychiatric condition that may requiresome type of specialty behavioral health care could reach 14.4million by 2030 (Institute of Medicine [IOM], 2012; Karel et al.,2012). As a category, psychiatric conditions constitute the thirdmost common debilitating health problem among the agingpopulation, and older adults with psychiatric conditions areamong the most costly Medicare beneficiaries (Alecxih, Shen,Chan, Taylor, & Drabek, 2010; IOM, 2012; Manton, Corder, &

Contents

The Geriatric Mental Health ChallengeRobert B. Hudson, Editor

More than 20 percent of older Americans experience a psychiatriccondition that may warrant behavioral health care intervention. Moreover,these individuals often face more than one such debilitating condition, and atadvanced ages, physical health problems may exacerbate mental health issuesin a reinforcing and destructive manner. To researchers and practitioners in themental health field—to say nothing of individuals with mental illness and theircaregivers—these realities are well known. But despite considerable attentionto these concerns—extending back to the Community Mental Health CentersAct of 1963 and the Nursing Home Reform Act associated with OBRA ’87—thehealth policy scorecard associated with mental illness is a spotty one at best. As the articles in this issue of Public Policy & Aging Report point out, issues ofdiagnosis and treatment, extensive use of pharmacological services,interventions with often inconclusive results, difficulties in translating clinicalresearch to community settings, and cultural attitudes toward mental illnessamong professionals and laypeople alike each present critical barriers to betteraddressing the needs of some 8 million older Americans experiencing a rangeof psychiatric conditions.

Brian Kaskie introduces the issue, briefly reviewing the breadth and depthof the geriatric mental health challenge. He then turns to needed interventions,focusing specifically on models of behavioral health care. After discussing anumber of promising models, he cites critical barriers to improved care:meeting a range of conditions simultaneously, recruiting and retaining qualified coordinators and psychiatrists, and addressing patient activation frominitial screening through a course of care. Particularly telling is his observationthat “the dissemination of evidence-based, integrated models of care fromacademic, grant-financed medical clinics into select community-based settingswill result in a considerable amount of so-called voltage drop” in modeleffectiveness. As do others, Kaskie concludes by arguing that integrated models should be seen as the preferred solution to addressing this wide range of problems. (The editors would like to thank Professor Kaskie for hisassistance with the organization of this issue of PP&AR.)

Jane Hudson and colleagues discuss the uneven history of the Pre-Admission Screening and Annual Resident Review, enacted as part of theNursing Home Reform Act in 1987. The goal was to reduce the use of physicaland medical restraints in nursing facilities, but subsequent experience has beendisappointing at best. Psychiatric medication therapy has remained the primary

1 Perspectives on the Pre-Admission Screening and Annual Resident Review Process:Why Can’t This Program Just Grow Up? / Jane Hudson • Lauren Erickson • Scott Lyon •Jayna Grauerholz • Jean Herrity

1 The Widespread Deployment of Integrated Models of Care / Brian Kaskie

10 Better Coordination of Care for Medicare Beneficiaries With Severe Mental IllnessCould Improve Quality of Life and Lower Costs / Sally Rodriguez

16 Expanding the Capacity to Treat Older Adults With Mental Health and Substance Use Conditions: A Workforce Policy Strategy / Christine E. Bishop

20 Antipsychotic Use in Individuals With Dementia: An Overview for Policymakers /Ryan M. Carnahan • Michael W. Kelly • Marianne Smith

24 Suicide in Later Life: The Role of Risk Factors, Firearm Policy, and Primary CarePhysicians / Mark S. Kaplan • William Coryell

Public Policy & Aging Report® is a quarterlypublication of the National Academy on an AgingSociety (www.agingsociety.org), a policy instituteof The Gerontological Society of America. Yearly subscription rate is $49 for members($59 international) and $60 for nonmembers($70 international). To subscribe or to purchase individualissues, visit www.agingsociety.org.Copyright 2013, The Gerontological Society ofAmerica. All rights reserved. No part of thispublication may be reproduced without writtenpermission.Disclaimer: Statements of fact and opinion in thesearticles are those of the respective authors andcontributors and not of the National Academy on anAging Society or The Gerontological Society of America.

ISSN 1055-3037

Public Policy & Aging Report®From the Editor

EditorRobert B. HudsonBoston [email protected]

Managing EditorGreg O’Neill

National Academy on an Aging [email protected]

Production ManagerMegan McCutcheon

The Gerontological Society of [email protected]

Editorial BoardJacqueline J. Angel

The University of Texas at Austin

Robert A. ApplebaumMiami University

Joseph F. CoughlinMIT AgeLab

Judith G. GonyeaBoston University

Neil HoweBlackstone Group

Kathryn G. KietzmanUCLA Center for Health Policy Research

Eric R. KingsonSyracuse University

Edward F. LawlorWashington University

Harry R. MoodyAARP

S. Jay OlshanskyUniversity of Illinois at Chicago

Sara E. RixAARP

James H. SchulzBrandeis University (Emeritus)

Keith E. WhitfieldDuke University

Joshua M. WienerRTI International

Gretchen E. AlkemaChair, GSA PPC CommitteeContinued on page 35

Volume 23, No. 3 Public Policy & Aging Report®


Stallard, 1993). Moreover, even though the prevalence rates formany psychiatric conditions actually decrease with advancingage, the probability of acquiring dementia and other late-onset psychiatric disorders increases, especially as theincidence of cancer, heart disease, and other fatal conditionsdecreases (Karel et al., 2012).

Psychiatric Conditions: Both Complex and CommonPerhaps the most intriguing aspect among recent efforts

to account for the prevalence of psychiatric conditions amongolder adults concerns an increased emphasis on the clinicalcomplexity, as well as the commonness, of co-occurring andcomorbid psychiatric conditions. On one hand, among olderadults with a single diagnosable psychiatric disorder, theproportion of those who also experience a second (or third)diagnosable psychiatric disorder or symptomatic conditionmay be as high as 40 percent (Gum, King-Kallimanis, & Kohn,2009). For example, older adults who are depressed may alsoexperience dementia; those who are anxious may also misuseprescription and illegal substances (IOM, 2012). In reviewingsymptoms identified by a comprehensive psychiatric screencompleted by more than 700 older adults who presented inthree primary health care clinics over a 6-month period,Kaskie, Kelly, and Lynch (2012) found positive screens amongslightly more than 30 percent of all older patients. An itemanalysis of 225 positive screens revealed that 97individuals (43%) experienced symptomatologyrelated to a single diagnostic condition; theremaining 128 individuals (57%) presentedmixed symptomatology, as indicated by acombination of at least one or more symptomsof cognitive problems, depression, anxiety, orsubstance misuse. Such co-occurring conditionsappear to be most common among those withneurocognitive disorders (Karel et al., 2012);

more than half of older individuals with dementia or mildcognitive impairment also experience depression, anxiety, and other behavioral disturbances (e.g., agitation). Such co-occurring conditions lead to a number of negative outcomes,such as increased health problems and higher use of hospitaland long-term care services, as well as decreased functioningand quality of life (Hybels, Pieper, & Blazer, 2009).

On the other hand, many older adults who experience a psychiatric condition also have a diagnosable healthcondition (Koenig & George, 1998; Proctor et al., 2003). Forexample, depressive conditions are more prevalent amongolder adults with cancer, individuals with dementia oftenalso have diabetes, and so forth. Such comorbid conditionshave been shown to complicate the provision of health careand have been associated with a number of negativeoutcomes, such as higher rates of suicide and mortalityin these individuals compared with older adults whoexperience either only a psychiatric condition or only ahealth condition (Lin, Zhang, Leung, & Clark, 2011). Morerelevant here, older adults who experience comorbidconditions are less likely to obtain specialty behavioralhealth care than younger populations. Instead, they tend toobtain care from physicians and other health care providerswho are not formally trained to identify and treat psychiatricconditions and thus not likely to refer older patients to

Table 1. Estimate of Prevalence of Mental Disorder, Including Dementia, in Adults 65 Years of Age and Older

Source: Adapted from Karel, Gatz, & Smyer (2012).

Prevalence of mental Prevalence of mental Total prevalence of mental disorder other than disorder other than disorder, including dementia,

Age group Prevalence Age group dementia for older adults dementia for older adults for older adults in the (years) of dementia (years) in the community in residential care community and in

residential care65–69 1.4% 65–74 96%

70–74 2.9%

75–79 7.6% 75–84 6.8%

80–84 18.6%

85–89 32.7% 85+ 8.1%

90+ 37.4%

Total 65+ 10.0% total 65+ 8.5% 31.5% 20.4%

As many as 8.6 million people over65 are thought to be experiencing apsychiatric condition.

behavioral health specialists(Noel et al., 2004).

In fact, despite theavailability of effectivetreatment options, less thanone out of every four olderpeople with a psychiatricdisorder obtains any type ofspecialty behavioral healthcare (Milazzo-Sayre et al.,2001). The pervasive failure to provide evidence-basedtreatment to older adults with psychiatric conditions,including those with co-occurring and comorbiddisorders, has been defined as a substantive public health policy problem(Administration on Aging,2001). Although several recent initiatives, such as the Medicare Mental HealthInpatient Equity Act of 2011,have been designed toidentify and remove barriersto specialty mental healthcare (also see Ostrow &Manderscheid, 2009;Sundararaman, 2009), themost effective response,arguably, has been toestablish integrated models of behavioral health care(Butler et al., 2008).

Integrated Models of CareIntegrated models bring

together specialty behavioralhealth care providers (and caremanagers) with health andsupportive service providers,who assume complementaryroles in serving people withpsychiatric conditions. Thesemodels—which capitalize onthe tendency of older patientswith psychiatric conditions toinitially present in health, long-term care, and other supportiveservice settings—are designedto identify, assess, and treatindividuals within the initialcare setting, linking patients to

Table 2. Twelve-Month Prevalence Rate and Estimated Number ofCommunity-Living Adults Ages 65 and Older for 10 Mental Health andSubstance Use Conditions

Mental health or substance use Prevalence rate (%) Estimated number of older (MH/SU) condition adults in 2010 (in millions)

Mental health conditionsDepressive disorders 3.0–4.5 1.2–1.8

Major depressive episode(s) 3.0–4.3 1.2–1.7

Dysthymic disorder 0.6–1.6 0.2–0.6

Panic disorder 0.8–1.1 0.3–0.4

Agoraphobia without panic a–0.3 a–0.1

Social phobia 0.9–2.6 0.4–1.0

Generalized anxiety disorder 1.1–2.1 0.4–0.8

Posttraumatic stress disorder (PTSD) 0.6–2.6 0.2–1.0

Substance use conditions

Alcohol dependence or abuse a–1.9 b–0.7

Drug dependence or abuse a–0.2 b–0.1

Summary figures

One or more of the conditions 6.8–10.2 2.6–4.0

One of the conditions 4.8–7.8 1.8–3.0

Two or more of the conditions 2.0–2.4 0.8–0.9

Three or more of the conditions 0.5–0.8 0.2–0.3

aThe prevalence rate is less than 0.2 percent. bThe number of people with the condition is lessthan 50,000. Reprinted with permission from the National Academies Press, copyright 2012,National Academy of Sciences.

Table 3. Twelve-Month Prevalence Rate and Estimated Number of Community-Living Adults Ages 65 and Older for Nine Additional Mental Health andSubstance Use Conditions

Mental health or substance use Prevalence rate (%) Estimated number of older (MH/SU) condition adults in 2010 (in millions)

Mental health conditionsBipolar disorder a–0.2 b–0.1

Schizophrenia 0.2–0.8 0.1–0.3

Obsessive-compulsive disorder 0.8 0.3

Depressive symptoms 1.1–11.1 0.4–4.3

Anxiety symptoms 4.3 1.7

Suicidal ideation 0.5–1.7 0.2–0.7

Suicide plans and attempts a b

Substance use conditions

At-risk drinking 5.2 2.0

At-risk drug use 0.9 0.4

aThe prevalence rate is less than 0.2 percent. bThe number of people with the condition is lessthan 50,000. Reprinted with permission from the National Academies Press, copyright 2012,National Academy of Sciences.





psychiatrists and other specialty behavioral health careproviders as needed. Integrated models have contributed toimproved health, mental health, functional status, and qualityof life, as well as other desirable clinical outcomes. Integratedmodels also have been shown to reduce aggregate andindividual health care costs (Kaskie & Buckwalter, 2010).

The number of integrated models targeting older adultshas increased substantially over the last 10 years (Callahanet al., 2011). One of the first integrated models targetingolder patients was the PROSPECT (Prevention of Suicide inPrimary Care Elderly: Collaborative Trial) program. PROSPECTdemonstrated that clinical outcomes for older adults withdepression improved when behavioral health care wasintegrated into primary health care settings (Bruce et al., 2004).The Improving Mood—Promoting Access to CollaborativeTreatment (IMPACT) program also has generated aconsiderable amount of evidence, suggesting that integratedmodels improve clinical outcomes for older adults withdepression (Unützer et al., 2002). The IOM (2012) reportreviewed a total of nine different integrated models andshowed how the models have diversified over time to addressdifferent conditions (e.g., depression, dementia, serious mentalillness), as well as various organization and staffing patterns.

Based on the successful outcomes, the President’s New Freedom Commission on Mental Health (Hogan, 2003)called for an expansion of such evidence-based integratedmodels targeting aging populations, and the Agency forHealthcare Research and Quality (AHRQ) validated the utility of PROSPECT, IMPACT, and other integrated models in providing care to older adults with psychiatric conditions(Butler et al., 2008). Subsequently, in 2011, AHRQ conveneda group of national experts who were involved in theadministration and evaluation of integrated models of caretargeting older adults (Kaskie, 2011). Altogether, the groupaccounted for eight distinct approaches to implementingsuch models within health and supportive service systemsand affirmed that integrated models constitute a standardof care for older adults with psychiatric conditions. The IOM(2012) recently called for the widespread deployment ofthese models within larger health care delivery systems.

Dissemination and Implementation EffortsThe Patient Protection and Affordable Care Act

formally supported such widespread dissemination andimplementation of integrated models of care. In particular,the Act recognized the critical role of specialty behavioralhealth care in overall health, authorized an initial allocationof $50 million with 5 years of continued funding, andassigned responsibility for model dissemination to thenational network of community mental health centers. In addition, the Centers for Medicare & Medicaid Servicesrecently approved discrete payment mechanisms critical to the financing of integrated models of care. Thesemechanisms include providing reimbursement for basic

screening of cognition, depression, and substance misuse,as well as establishing co-payment parity for outpatientbehavioral health care (Kautz, Mauch, & Smith, 2008; U.S.Department of Health and Human Services, 2012).

Medicare Advantage Plans also are being tapped as ameans to deploy integrated models of care to older adults withpsychiatric conditions. In particular, Medicare Special NeedsPlans have emerged as a type of Medicare Advantage Plan thatwould support the integrated models of care for beneficiarieswith dementia and other psychiatric conditions (MedicarePayment Advisory Commission, 2012). Notably, MedicareSpecial Needs Plans go one step further than the traditionalintegrated model by aligning Medicare and Medicaid financingand benefits structures, so that acute and long-term servicesfor individuals with dementia and behavioral health needs alsocan be coordinated.

The formation of Medicare Accountable Care Organizationspresents another opportunity to deploy integrated models of

Figure 1. Clinical model using the MentalHealth Screen for Older Iowans.

1. ScreeningIf patient screens positive

for mental health problem,then proceed.

2. Counseling & ReferralDiscuss the importance of

mental health care.

Schedule diagnosticassessment.

3. Diagnostic AssessmentTesting

Interview

Begin patient and familyeducation.

4. TreatmentTreatment plan agreement

Problem solvingtherapy

5. Evaluation

Pharmacy approaches

Supportiveservices



care, under the assumption that psychiatric conditionsconstitute chronic, complex, high-cost conditions that requirecoordinated clinical care (Druss & Mauer, 2010). In fact, theVeterans Affairs Health Care System already has begun suchdissemination and implementation efforts, incorporatingintegrated approaches into primary care clinics, home-based settings, and long-term care residential settings, aswell as aligning processes of care within the chronic-diseaseframework (Zeiss & Karlin, 2008).

The Road AheadArguably, the dissemination of evidence-based,

integrated models of care from academic, grant-financedmedical clinics into select community-based settings willresult in a considerable amount of so-called voltage drop,and such shortages will become even more pronounced asimplementation efforts spread across larger service systems(Kilbourne et al., 2007). In particular, individual outcomesobserved in the initial model evaluations are less likely tooccur or to be as pronounced when translated into a greaternumber and variety of settings. These shortcomings mostoften relate to patient, provider, organizational, andcontextual factors that were not as relevant in the morecontrolled settings in which the models were originally

developed and evaluated, andonly become salient as effortsmove toward widespreadtranslation (Kimberly & Cook,2008). Indeed, as part of the2011 AHRQ conferencefocusing on integrated modelsof care for older adults, severalchallenges concerning thewidespread dissemination andimplementation of suchmodels were identified.

Scope of practice. Effortsto translate the integratedmodel of behavioral healthcare must move beyondfocusing on one psychiatriccondition or another (e.g.,depression or cognitiveimpairment), if only because the complexity andcommonality of co-occurringand comorbid disordersamong older patientsnecessitates that the range of conditions be consideredsimultaneously. For example,rather than solely focusing ondepression, researchers at theUniversity of Iowa (Kaskie &

Buckwalter, 2010) developed the 15-item ComprehensivePsychiatric Screening Tool for Older Adults, which essentiallyis a composite of short-item screens for symptoms related toanxiety, depression, alcohol and prescription drug misuse,thinking and memory, and psychological distress. Moreover,as integrated models move into larger service systems,greater emphasis should be placed on a comprehensive andcoordinated diagnostic assessment following a positivescreen. The assessment not only should identify and separateco-occurring and comorbid disorders but also should record apatient’s preferences, motives, and capacities for participationin treatment (Knight, Kaskie, Shurgot, & Dave, 2006).

Provider engagement. Although many of the well-established integrated models rely on qualified carecoordinators and psychiatrists, creating a dedicated staffingposition represents a challenge for many clinics that neitherhave the resources nor experience sufficient patient volumeto warrant the hiring of a new staff member. Instead, mostindividual clinics and health systems are likely to rely onexisting staff to conduct patient screening, referral, andtreatment. Given that the majority of primary carephysicians and nurses are not trained to identify and treatpsychiatric conditions among older adults, the successfuldeployment of the integrated model will need to include a

Table 4. Integrated Models of Care

Model Target population

Depression

Improving Mood—Promoting Access to Older adult population with major depression, Collaborative Treatment (IMPACT) dysthymic disorder, or both

Kaiser Nurse Telehealth Care Model Adult population (all ages) starting antidepressant drug therapy

Program to Encourage Active, Rewarding Older, community-residing adults with minor Lives for Seniors (PEARLS) depression and dysthymia who are receiving

social services

Substance use

Screening, Brief Intervention, and Referral Older adult population at risk for alcohol and to Treatment (SBIRT) substance misuse

Primary Care Research in Substance Abuse Older primary care patients with symptoms of and Mental Health for the Elderly (PRISM-E) depression, anxiety, and at-risk drinking

Serious mental illness

Helping Older People Experience Older adults with serious mental illness Success (HOPES) residing in the community

Psychogeriatric Assessment and Treatment Older adults with serious mental illness living in in City Housing (PATCH) urban public housing

Wellness Recovery Action Plan (WRAP) Adults (all ages) with severe and persistent mental illness

Psychiatric and behavioral symptoms related to dementiaProviding Resources Early to Vulnerable Older adults with Alzheimer’s and their Elders Needing Treatment (PREVENT) caregivers



concerted effort to educate and engageexisting staff (IOM, 2012). Recognizing thatmost primary care staff have neither the timeto participate nor an interest in participating insuch time-intensive (and often off-site) trainingefforts, researchers at the University of Iowacreated an easy-to-use iPad trainingapplication that presents information aboutintegrated models of care in multiple mediumsmost conducive to adult learners. The 1-hourtraining has been approved for continuing medicaleducation credits and has been reviewed favorably byprimary care providers who indicated that, uponcompletion, they felt more informed about the goals ofintegrated care models, better understood their roles inproviding integrated care, and had increased theirappreciation of behavioral health care.

Patient activation. Perhaps the biggest challengefacing the widespread success of integrated modelsconcerns the number of patients who initially screenpositive for psychiatric symptoms but then fail to progressthrough the remaining course of care (Aarons & Sawitzky,2006). For example, our experience in Iowa (Kaskie &Buckwalter, 2010; Kaskie et al., 2012) revealed that fewer than20 percent of the older adults who screened positive went onto complete a diagnostic assessment, and only half of thoseinitiated treatment—an outcome not unlike what has beenreported elsewhere. We determined the most commonreason for the lack of activation was that older patientsreportedly were not interested in progressing further, citingany number of issues—such as difficulty coming back to theclinic for an assessment appointment—or discounting theirsymptoms as situational and not likely to persist.

The second most common source of inactivation waslack of direction from the attending physician, who mostoften preferred to adopt a wait-and-see approach ratherthan order and schedule a diagnostic assessment forsomeone with positive symptomatology. In response to this situation, individual clinics should increase patient-education efforts by developing a set of educationalmaterials that familiarize older patients with the range ofdisorders and how they can affect quality of life. Clinics alsoshould offer handouts to those who screen positive butdecline assessment. These handouts could review the goalsand objectives of integrated care, offer options about when,where, and how to complete assessment and treatment, andprovide contact information patients can use when they areready to activate. Analysis of data from three clinics in Iowashowed that activation increased when patients wereinformed that they could request to complete theassessment at home (Kaskie et al., 2012). Also, we observedthe deployment of an electronic medical record system thatscheduled patient screenings and assessments, serving toincrease participation perhaps by nudging older patients

and primary care providers, as well as effectively creating adecision that had to be negated rather than affirmed.

System adaptation. Evidence has suggested that theonly area in which Medicare Advantage Plans are not doingwell is with regard to the quality of care provided toindividuals with psychiatric conditions (Loftis, 2006). Thisgap may correspond with variations in how managed careorganizations have applied administrative policies andservice management practices when designing provision of care to older adults with psychiatric conditions (Kaskie,Gregory, & Cavanaugh, 2008; Kaskie, Wallace, Kang, &Bloom, 2006). For example, some systems may focus only on serving select types of psychiatric conditions (e.g.,depression), whereas others actively refer the more complexcases to other systems (e.g., leaving people with dementiato long-term care and aging service programs). Moreover,relying on the public mental health system to deployintegrated models of care is particularly troublesomebecause the national network of community mental healthcenters, which the Patient Protection and Affordable CareAct has called upon to disseminate the collaborativemodels, has never displayed much interest in serving theaging population. In fact, the role of public mental healthsystems in serving older adults was curtailed substantiallyduring the 1990s and, since then, little effort has been madeto reclaim people over 65 as a patient population (Kaskie,Gregory, & Van Gilder, 2009). As such, expectations aboutdeploying integrated models of care that target older adultswith psychiatric conditions within two of the largest types ofcare delivery systems should be tempered until a greaterinvestment is made in research designed to identify andaddress the most critical contextual and organizationalfactors associated with successful model translation.

Financing. Another impediment to the widespreaddissemination and implementation of evidence-based modelsof care corresponds with lack of adequate financing andcompetitive incentives (Druss & Mauer, 2010). For example, aslong as inpatient scatter beds used to care for individuals withpsychiatric conditions continue to receive up to 20 percentmore in patient reimbursement per day than dedicatedinpatient psychiatric beds (Kelly, 2011), health system actuarialanalyses will continue to resolve that the financial gains ofdeploying specialty behavioral health care—includingintegrated models that enlist care managers and other

Many older adults who experience apsychiatric condition also have adiagnosable health condition.



nonreimbursable expenses—result in a net loss relative tocurrent approaches. Until Medicare financing—whether it beunder fee-for-service, capitated, or bundled payments—canbe aligned with the clinical processes of integrated models,the deployment of integrated models will remain limited.

ConclusionsThe growing population of older adults brings with it

a rising number of older adults with psychiatric conditions.Historically, despite the development of evidence-basedtreatment approaches, these individuals have been the leastlikely of any population group to receive effective treatment.Although several alternative solutions have been proposed toaddress this public-health-policy problem, one of the mostviable has been to establish integrated models of care inwhich behavioral health specialists are embedded in thehealth and supportive service settings most often used byolder adults. As efforts continue to expand the deployment of these models into larger systems of care, policymakers andprogram administrators should be most concerned with thepotential drop-off in model effectiveness. Researchers couldassist in this effort by working to identify the variables mostcritical in advancing patients through the process ofintegrated care (i.e., activation); understanding how modeltranslation varies across health care and other large systems in terms of contextual, organizational, provider, and individualpatient factors; and delineating the costs and benefits relatedto model implementation under fee-for-service, capitated, andbundled financing mechanisms.

Brian Kaskie, PhD, is an associate professor of healthmanagement and policy, College of Public Health, University ofIowa, and serves as associate director of public policy, Centeron Aging, University of Iowa.

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Kautz, C., Mauch, D., & Smith, S. A. (2008). Reimbursement ofmental health services in primary care settings (HHS Pub. No.SMA-08-4324). Rockville, MD: U.S. Department of Healthand Human Services.

Kelly, D. (2011). Improving payment and care under Medicareinpatient psychiatric benefit. Washington, DC: MedicarePayment Advisory Commission.

Kilbourne, A. M., Neumann, M. S., Pincus, H. A., Bauer, M. S., &Stall, R. (2007). Implementing evidence-basedinterventions in healthcare: Application of the replicatingeffective programs framework. Implementation Science,42(2), 1–10.

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Koenig, H. G., & George, L. K. (1998). Depression and physicaldisability outcomes in depressed medically ill hospitalizedolder adults. The American Journal of Geriatric Psychiatry, 6,230–247.

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Definitions and, thus, estimates of SMI differ based onthe parameters of the research, but there is broad agreementthat these illnesses are prevalent among older Americansand dual-eligible Medicare and Medicaid beneficiaries. TheInstitute of Medicine estimates that approximately 5.6million to 8 million Americans 65 years of age or older havemental health or substance use disorders (SUDs); thatnumber is expected to reach 10.1 million to 14.4 million by2030 (Bartels & Naslund, 2013). Other analyses estimate thatabout one in four older Americans has a major psychiatricdisorder (Bartels, Blow, Brockmann, & Van Citters, 2005), suchas depression or anxiety disorders, and more than 1.7 millionolder Americans have a SUD (Gfroerer, Penne, Pemberton, &Folsom, 2003).

SMIs are extremely disabling and present severalchallenges to the preservation of physical health,functioning, and quality of life. A large body of evidenceshows that people with SMI have higher mortality rates, are less likely to receive needed care, and are more likely toexperience other chronic conditions (Husaini et al., 2002).Individuals with SMI and SUD have particular difficultymanaging their SMI and other conditions, and are at highrisk for hospitalization and homelessness (Mechanic, 2012).One contributing factor to breakdowns in care is that SMIcan hinder communication between health practitionersand patients when they do seek care (Husaini et al.). Theseeffects of SMI often combine to result in patients failing tomanage their SMI, SUD, and chronic conditions, and onlypresenting in health care settings when their conditionshave greatly worsened—often in high-cost settings, such asthe emergency room and hospital inpatient wards (Husainiet al.). In fact, one study found that people with SMI and

chronic conditions had 30 percent to 80 percent highermedical spending than those with chronic conditions andno SMI (Gruber, Locke, & Marcus, 2012).

Data, Methods, and Findings of New AnalysisData sources and definitions. We used the 2010

Medicare Standard Analytic Files, or fee-for-service claimsdata, to analyze inpatient service use and Medicare Part Aspending associated with three groups of fee-for-serviceMedicare beneficiaries: those without an SMI diagnosis,those with any SMI diagnosis, and a subgroup of the SMIbeneficiaries with both an SMI and a SUD diagnosis. Todefine SMI, we conducted a literature review to determinewhich kinds of mental illnesses to include in the definition.The definition of serious or severe mental illness variedthroughout the literature; we did not find a generallyaccepted list of conditions designated as SMI. In consultationwith experts, we included the types of mental illnesses thatare considered most disabling: major depression, bipolardisorder and other mood disorders, and schizophrenia andother psychoses. For the purpose of this analysis, a Medicarebeneficiary had SMI or SUD or both if he or she had anyclaim indicating at least one of the selected diagnosis codesduring 2010. To identify the number of co-occurring chronicconditions for each beneficiary, we used the ClinicalClassifications Software tool; any conditions included in thetool that fell under our SMI definition were excluded fromthe total co-occurring chronic conditions number.

Methods. We calculated per capita Medicare spendingand inpatient use data for beneficiaries with no SMI, anySMI, and SMI plus SUD. To compare spending and use forthese groups, we calculated the inpatient and total

Better Coordination of Care for Medicare Beneficiaries With Severe Mental Illness Could Improve Quality of

Life and Lower CostsSally Rodriguez

IntroductionNever before has the need to find and understand high-cost patient populations been as urgent as it is now. The fee-

for-service Medicare program is facing deficit reduction pressure, managed care organizations are bidding to enroll moreMedicare and Medicaid beneficiaries, and many providers are experiencing the beginning phases of provider-based riskmodels, such as accountable care organizations and bundled payment arrangements. This array of pressures raises two veryimportant questions: What are the characteristics of high-cost patient populations, and what can be done to reduce theirspending? One of the least understood high-cost groups of Medicare and Medicaid beneficiaries are those with severemental illness (SMI). Most research to date has focused on younger Medicaid beneficiaries with mental illness, but newevidence reveals how SMI in Medicare-only and dual-eligible beneficiaries exacerbates chronic illnesses and long-term careneeds, leading to adverse events and higher-than-average Medicare spending.


Better Coordination of Care for Medicare Beneficiaries With Severe Mental Illness Could Improve Quality of Life and Lower Costs

Medicare Part A spending and service use, both overall andper capita. To produce the number of hospital readmissionsper beneficiary, we flagged any episode of care beginningwith a short-term acute care hospital stay that included anadditional short-term acute care hospital stay within 30 daysof the initial stay. Initial or index short-term acute carehospital stays were only considered as such if no additionalhospital stay had occurred within the prior 30 days.

Limitations. Some definitions of mental illnesssuggest a look-back period of multiple years whensearching diagnoses codes in claims data; therefore, our analysis may undercount the true number of Medicare beneficiaries with SMI. However, in accordance with our emphasis on mental illnesses that arethe most disabling, we concluded that thepresence of any claim with an SMI diagnosiswithin 1 year of data was sufficient to establishthe presence of a significantly disablingmental illness.

Findings. Our analysis found that nearly 3million Medicare beneficiaries were treated foran SMI diagnosis in 2010. Among beneficiarieswith an SMI diagnosis, the most common

types of conditions were major depression (45%) andschizophrenia and other psychoses (44%). Unsurprisingly,younger and dual-eligible Medicare beneficiaries weredisproportionately treated for SMI; although theyrepresented only 20 percent of beneficiaries in our sample,dual eligibles accounted for 48 percent of all Medicarebeneficiaries with an SMI diagnosis; similarly, although only representative of 21 percent of beneficiaries in oursample, the under-65 group made up 51 percent of totalbeneficiaries with an SMI diagnosis. Younger and dual-eligible beneficiaries also had a higher prevalence of co-occurring SUD diagnoses. In contrast, older beneficiarieswith SMI had a higher prevalence of other non-SUD chronicconditions (see Table 1). Our findings are in accordance withexisting research related to older Americans and dualeligibles with SMI. Our total prevalence figures may appearlow in comparison with some estimates, most likely becausewe looked at a narrower set of mental illnesses that areconsidered significantly disabling and we did not capturedata on individuals with SMI who did not receive treatmentfor SMI in 2010.

The presence of SMI had a strong effect on total percapita Medicare spending (see Table 2). Medicare-onlyand dual-eligible beneficiaries with SMI had higher averageMedicare spending than their counterparts without SMI, afinding that is particularly pronounced in the populationages 65 and older. Perhaps more compelling is the uptick in spending for beneficiaries with both SMI and SUD; in allage and dual-eligibility status groups, per capita spendingon beneficiaries with SMI and SUD was at least twice asmuch as per capita spending for beneficiaries with SMI only.The combination of SMI and multiple chronic conditionswas also associated with significantly higher per capitaspending, and the presence of SUD magnified this effect(see Table 3).

Beneficiaries with cardiovascular disease or diabetesor both typically incur higher-than-average Medicarespending related to their ongoing care, and SMI furtherincreases this spending. We found that having any SMIdiagnosis was associated with about a twofold increase in per capita Medicare spending. This finding is consistentwith research suggesting that diabetes and cardiovasculardisease can exacerbate SMI, and vice versa; someantidepressants have been linked with diabetes

Table 1. Severe Mental Illness (SMI) Diagnoses,Substance Use Disorders (SDU), and MedicareSpending for All Medicare Beneficiaries, by Number of Co-Occurring Chronic Conditions, 2010

Number of Percent with three fee-for-service or more co-occurring beneficiaries 2010 chronic conditions

Non-duals <65

w/o SMI 2,970,740 14.1%w/ SMI 497,480 15.9%w/ SMI + SUD 22,000 17.9%

Duals <65


Non-duals 65+


Duals 65+


All beneficiaries

w/o SMI 27,168,360 25.8%w/ SMI 2,796,360 33.9%w/ SMI + SUD 107,200 22.8%

Nearly 3 million Medicarebeneficiaries were treated for asevere mental illness in 2010.

prevalence, and psychotropicmedications prescribed for SMI can cause weight gain, which caninterfere with care for diabetes andcardiovascular diseases (Husaini et al.,2002; McCloughen & Foster, 2011).Beneficiaries with thesecombinations of conditions may beparticularly at risk for high Medicarespending and may warrant specialattention in efforts to improve caredelivery and coordination (Frayne et al., 2005).

SMI and inpatient use. Among allMedicare beneficiaries, SMI diagnoseswere associated with higher inpatientuse and spending; just under 40percent of beneficiaries with SMI andover 80 percent of beneficiaries withSMI and SUD used inpatient services in2010. In comparison, about 17 percentof beneficiaries without SMI had aninpatient stay. Accordingly, Medicarebeneficiaries with SMI incurred threetimes as much inpatient spending asthose without SMI ($7,604 and $2,523,respectively). The presence of SUDagain magnifies the effect onspending; Medicare spent $18,696 per capita for inpatient stays for thosebeneficiaries. We also found thatbeneficiaries with SMI had significantlyincreased rates of 30-day all-causehospital readmissions, and rates wereparticularly high for those with SMIand SUD (see Table 4). Again, these results are in accordancewith published research that demonstrates higher use ofemergency department and hospital services amongMedicare beneficiaries with SMI (Merrick, Perloff, &Tompkins, 2010).

Discussion and Policy ImplicationsThese findings make a compelling case that the

presence of SMI complicates treatment plans amongMedicare beneficiaries, causing them to use more healthcare, more often in hospitals, than their counterpartswithout SMI. The often fragmented systems of primary,acute, and behavioral health care, particularly amongentities serving dual eligibles, may contribute to thedifficulty in managing SMI. These breakdowns in careultimately result in high costs that are borne by publicprograms; in 2005, Medicaid, Medicare, and other publicprograms accounted for more than 50 percent of allmental health expenditures (Substance Abuse

and Mental Health Services Administration, 2012).The link between SMI, SUD, and co-occurring chronic

conditions and their effect on Medicare spending andinpatient use is clear. Currently, Medicare coverage ofmental health services is somewhat limited, does notemphasize home-based services, and includes a relativelyhigh 50 percent co-payment for psychologically basedservices. Dual eligibles must navigate an even morecomplex patchwork of Medicare- and Medicaid-coveredservices to obtain needed care. The key question facingpolicymakers and health care providers is, how can physical,behavioral, and long-term care be improved andcoordinated for these beneficiaries? Moreover, as healthreform progresses, can new health care delivery andfinancing models be used to create a system that is betterprepared to care for these patients?

Health reform efforts bolstered by the Affordable CareAct (ACA) present an opportunity to meaningfully affect



Table 2. Per Capita Medicare Part A Spending for All Beneficiariesby SMI, SUD, Age, and Dual Eligibility Status, 2010

$50,000

$45,000

$35,000

$30,000

$25,000

$20,000

$15,000

$10,000

$5,000

$0 Medicare-Only,Age <65

Medicare-Only,Age 65+

Dual Eligibles, Age <65

Dual Eligibles, Age 65+

$6,438

$12,014

$26,479

$10,440

$14,329

$30,562

$7,191

$22,629

$39,256

$11,325

$27,364

$49,625Without SMIWith SMIWith SMI and SUD

Table 3. Per Capita Medicare Part A Spending for All Beneficiaries, By SMI,SUD, and Dual Eligibility Status, and Number of Chronic Conditions, 2010

$70,000

$60,000

$50,000

$40,000

$30,000

$20,000

$10,000

$0 Non-Duals,0–2 CCs

Duals,0–2 CCs

Non-Duals,3+ CCs

Duals,3+ CCs

$3,805$8,498

$20,778$16,981

$35,888

$51,896

$4,942$9,136

$24,278 $25,106

$40,479

$60,547

Without SMIWith SMIWith SMI and SUD



quality of life for Medicare and Medicaid beneficiaries with SMI, as well as to dramatically reduce the spendingassociated with these beneficiaries. An estimated 3.7million more people with SMI will gain access to carethrough the expansion of Medicaid and private insuranceoptions (Sorrell, 2012). The Medicare program is seeing ashift from the traditional fee-for-service model toapproaches that encourage or borrow elements ofmanaged care. One such model is the accountable careorganization, which was authorized by the ACA forimplementation within the Medicare program.Accountable care organizations consist of networks ofproviders that coordinate all Medicare-covered servicesfor enrolled beneficiaries. Providers who successfullymanage care and reduce overall Medicarecosts can share in the savings they generate.

Although the accountable care modeldoes not provide an explicit incentive tointegrate behavioral health care, given thehigh spending associated with beneficiarieswith SMI, the potential for providers toachieve shared savings could be enhancedby the inclusion of these services. Asaccountable care organizations get up and

running, policymakers should consider ways to encourageproviders to focus on the treatment of beneficiaries withSMI. For example, accountable care organizations mustmeet certain quality metrics to achieve savings; morebehavioral health-specific measures could be included inthe measure set. As benefits and payments evolve undernew managed care approaches within Medicare, it iscritical that they acknowledge the challenges of providingeffective care for beneficiaries with SMI.

Other ACA initiatives provide opportunities tospecifically target Medicare and Medicaid beneficiaries vianew delivery systems and financing models. Specifically,state options to employ health homes and participate inthe Financial Alignment Initiative, or duals demonstration,

Table 4. Inpatient Hospital Use and Readmissions for All Medicare Beneficiaries by Severe Mental Illness(SMI) and Substance Use Disorder (SUD) Diagnoses, 2010

Number of fee- Percent with Inpatient Inpatient Inpatient as Percent of for-service inpatient spending claims percent of inpatient users beneficiaries claim per user per user total spending with readmission

Non-duals <65

w/o SMI 2,970,740 14.8% $15,265 1.60 35.1% 14.1%w/ SMI 497,480 31.1% $18,067 2.09 46.7% 16.2%w/ SMI + SUD 22,000 82.1% $20,644 2.99 64.0% 17.6%

Duals <65


Non-duals 65+


Duals 65+


All beneficiaries

w/o SMI 27,168,360 17.0% $14,810 1.55 32.5% 13.3%w/ SMI 2,796,360 39.0% $19,518 2.15 40.8% 18.7%w/ SMI + SUD 107,200 83.7% $22,329 3.24 59.9% 21.1%

Severe mental illness diagnoses wereassociated with higher inpatient useand Medicare spending.



provide excellent opportunities to coordinatecare and services for beneficiaries with SMI.The duals demonstration providesopportunities for states to integrate thefinancing and care delivery for dual eligibles.States can choose to finance these programsthrough a capitated—or per-member per-month—approach, or through a managedfee-for-service model. To better coordinate allcovered services, states can employ a numberof care delivery models to integrate all aspectsof patient care. At the time of this writing, 22states are pursuing inclusion in the demonstration, and some are specifically targeting dual eligibles with SMI. For example:

• Massachusetts has proposed to enroll dual eligiblesages 21 to 64 with full MassHealth and Medicarebenefits. Notably, covered services includeadditional behavioral health services, such ascommunity crisis stabilization, community supportprograms, treatment and support services forsubstance abuse, and psychiatric day treatment.Using individualized care plans directed by enrollees, Massachusetts aims tointegrate medical, behavioral health, and long-term care services.

• New York seeks to enroll dual eligibles with SMI or two or more chronic conditions (includingsubstance abuse) and fewer than 120 days of long-term care use into a managed fee-for-servicemodel. Beneficiaries’ care will be managed throughhealth homes, which must establish a network thatincludes hospital systems, ambulatory care sites,community-based organizations, and managedcare plans.

States also have more flexibility to implement thehealth home model, in which designated providers andteams of health professionals coordinate all aspects ofpatient care within their Medicaid programs. This modelallows community health centers and other behavioralhealth entities to manage the entire continuum of care forenrollees, across a variety of provider types and settings.

As of this writing, 11 states have applied for enhancedfederal matching funds for their health home programs. In their approved plans, Alabama, Idaho, Iowa, Maine,Missouri, New York, Ohio, Oregon, and Rhode Islandspecifically include beneficiaries with SMI and, in manycases those with co-occurring substance abuse andchronic condition diagnoses.

Although the ACA provides new authority and financialmomentum to implement such models as accountable careorganizations and health homes, current provider networksmay not be equipped to work together to handle the needsof this complex population. Fortunately, examples ofinnovative models and programs that policymakers andproviders can draw from to design their own programs areavailable. Comprehensive care models, such as the chroniccare model, can improve outcomes for beneficiaries withSMI and other chronic conditions and may work within theaccountable care organization and health home models.Existing chronic care model programs can provide strongclinical and policy frameworks for integration of multipleservices (Woltmann et al., 2012). In addition, the IntegratedCare Resource Center provides technical assistance andsupport for states developing programs to integratemedical, behavioral health, and long-term care for dualeligibles (Hamblin, Verdier, & Au, 2011).

In Pennsylvania, a unique Medicaid-led pilot programwas devised to improve care integration for adults withSMI. Medical care was provided through risk-bearingmanaged care organizations and behavioral health carewas offered through county-administered behavioralhealth managed care organizations. An independentevaluation of the pilot from 2009 through 2011 found

a 12 percent decrease in SMI-relatedhospitalizations, a 10 percent decrease inall-cause readmissions, and a 9 percentdecrease in emergency department use(Kim, Esposito, & Higgins, 2012). Thesuccessful Pennsylvania pilot led to thecreation of UPMC Community Care, aMedicare Special Needs Plan jointlyestablished by the University of PittsburghMedical Center and Community Care

Health reform efforts present anopportunity to meaningfully affectquality of life for beneficiaries withsevere mental illness.

Comprehensive care models canimprove outcomes for beneficiarieswith severe mental illness.



Behavioral Health. The plan targets Medicare-only anddual-eligible beneficiaries in specific geographic locationsand is financed through a capitated model that includes aprovision allowing participating providers and plans toretain savings derived from improved health outcomesamong plan enrollees.

As the ACA is implemented, the momentum generatedby the formation of accountable care organizations, theduals demonstration, and expansion of the health homemodel will generate many opportunities to improve carecoordination for beneficiaries with SMI within the Medicareand Medicaid programs. However, to achieve success, otherfederal agencies serving older adults must also focus onthese beneficiaries and their unique needs. Traditionally, the mental health system has operated independently, and a key challenge lies in its reintegration with Medicare,Medicaid, and other federal programs that support olderAmericans and individuals with disabilities. This effort would benefit from a cohesive federal effort but, as the true laboratories of policy, states can look to promising caremodels that have the potential to reduce health care costs,both to themselves and the federal government. At theprovider level, the movement toward assuming risk for thequality and costs of care means that it is imperative toidentify and coordinate care for key populations of heavyservice users for whom new care coordination initiativescould have a high probability of success. Clearly, Americanswith SMI, co-occurring chronic conditions, and SUD comewith unique care management challenges, but they alsorepresent a key opportunity to bend the overall health care cost curve.

Sally Rodriguez, MPH, formerly an analyst for the U.S.Government Accountability Office, is a senior manager atAvalere Health, Washington, D.C.

AcknowledgmentThis study was funded in part by The SCAN Foundation.

ReferencesBartels, S. J., Blow, F. C., Brockmann, L. M., & Van Citters, A. D.

(2005, August). Substance abuse and mental health amongolder Americans: The state of the knowledge and futuredirections. Rockville, MD: Westat.

Bartels, S. J., & Naslund, J. A. (2013). The underside of thesilver tsunami—Older adults and mental health care. NewEngland Journal of Medicine, 368, 493–496.

Frayne, S. M., Halanych, J. H., Miller, D. R., Wang, F., Lin, H.,Pogach, L., . . . Berlowitz, D. R. (2005). Disparities indiabetes care: Impact of mental illness. Archives of InternalMedicine, 165, 2631–2638.

Gfroerer, J., Penne, M., Pemberton, M., & Folsom, R. (2003).Substance abuse treatment need among older adults in2020: The impact of the aging baby-boom cohort. Drugand Alcohol Dependence, 69, 127–135.

Gruber, D., Locke, S., & Marcus, N. (2012). Behavioral health:Keys to reducing chronic disease costs. Managed CareOutlook, 25(24), 1, 3, 5–8.

Hamblin, A., Verdier, J., & Au, M. (2011, October). Stateoptions for integrating physical and behavioral health care.Baltimore: Integrated Care Resource Center, Centers forMedicare & Medicaid Services.

Husaini, B. A., Sherkat, D. E., Levine, R., Bragg, R., Holzer, C.,Anderson, K., . . . Moten, C. (2002). Race, gender, andhealth care service utilization and costs among Medicareelderly with psychiatric diagnoses. Journal of Aging andHealth, 14, 79–95.

Kim, J. Y., Esposito, D., & Higgins, T. C. (2012, October). SMIInnovations Project: Southwest Pennsylvania case study—The Connected Care pilot program. Princeton, NJ:Mathematica Policy Research.

McCloughen, A., & Foster, K. (2011). Weight gainassociated with taking psychotropic medication: Anintegrative review. International Journal of Mental HealthNursing, 20, 202–222.

Mechanic, D. (2012). Seizing opportunities under theAffordable Care Act for transforming the mental andbehavioral health system. Health Affairs, 31, 376–382.

Merrick, E. L., Perloff, J., & Tompkins, C. P. (2010). Emergency department utilization patterns for Medicarebeneficiaries with serious mental disorders. PsychiatricServices, 61, 628–631.

Sorrell, J. M. (2012). The Patient Protection and AffordableCare Act: What does it mean for mental health services forolder adults? Journal of Psychosocial Nursing, 50(11), 14–18.

Substance Abuse and Mental Health Services Administration.(2012). Mental health, United States, 2010 (HHS PublicationNo. [SMA] 12-4681). Rockville, MD: Author.

Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H.,Kilbourne, A. M., Bauer, M. S. (2012). Comparativeeffectiveness of collaborative chronic care models formental health conditions across primary, specialty, andbehavioral health care settings: Systematic review andmeta-analysis. The American Journal of Psychiatry, 169,790–804.


The hazards of workforce projections and policy are magnified for the needs and specialty care of anysubpopulation—hazards that seemed especially daunting asthe Institute of Medicine (IOM) Committee on Mental HealthWorkforce for Geriatric Populations began its work in 2011.However, committee members and staff avoided many ofthese pitfalls in the report they generated (Institute ofMedicine [IOM], 2012), taking a broad view of the workforcecapacity required to serve future older adults with mentalhealth and substance use (MH/SU) needs. The committee’sapproach was a necessary compromise: Over the nextdecades, the distance between the projected MH/SU needs of older adults and the numbers of specialized professionalswho might address them is so great that there is almost noway new policies could bridge the gap. But this approach alsopromises a more effective and less costly means to address anunder-recognized source of health care costs and hardship.

The need for the services MH/SU personnel couldprovide is indeed very large. Chapter 2 of the committee’sreport (IOM, 2012) reviews available statistics on theprevalence of MH/SU disorders in the older adultpopulation. Of special note, several portions of the olderadult population have never had adequate MH/SU specialtyservices, and their health situation promises to becomemore complex in coming years:

• Older adults receiving medical treatment for chronicdisease often need but do not receive specialtytreatment for MH/SU disorders as a comorbidcondition.

• Older adults at risk for problem drinking are under-identified and undertreated in primary care, theirmain point of contact with the health system, andabuse of other drugs appears to be on the rise asthe baby boomers age.

• Like other members of their generations, individualswith serious and persistent mental illness are livinglonger, and so will have MH/SU specialty needsalong with the chronic conditions that accompanyolder ages.

• Older adults using long-term services and supportsfor functional disability—home-care recipients andnursing home residents—often experience MH/SUneeds, especially undiagnosed depression.

• Rural and other isolated older adults have especiallypoor access to MH/SU specialty services.

For all of these groups, unmet MH/SU needs havebeen shown to complicate the treatment of otherconditions; for example, older adults with untreateddepression are less likely to follow prescribed medicationregimens for other health conditions, a factor associatedwith greater risk of hospitalization (Gehi, Haas, Pipkin, &Whooley, 2005; Jiang et al., 2001). As payers press forbetter management of chronic disease to contain healthcare costs, effective MH/SU treatment for older adultscould help bend the cost curve.

Not surprisingly given the current level of unmet need,projections of the geriatric MH/SU specialty workforcereveal that there will not be enough professionals withgeriatric MH/SU specialization to meet future needs.Psychiatrists are already in short supply, and psychiatryresidents seldom choose to spend an extra year for ageriatric specialization when provision of psychiatricservices for older adults can be less well compensated thantreatment for children or younger adults. The same appliesto nurses, who must spend additional time and tuition togain psychiatric and geriatric certification, only to fill jobs insettings where pay is generally lower than what they couldmake without these credentials. Other professionals are

Expanding the Capacity to Treat Older Adults With Mental Health and Substance Use Conditions:

A Workforce Policy StrategyChristine E. Bishop

National planning efforts for the health workforce have a long and venerable history—of missing the mark. When basedon projected growth in need for services and current use and supply patterns, policy recommendations often represent awish list for new supply to avert a predicted doomsday of massive unmet need. With health services jobs tightly defined bystate practice acts and professional credentialing, planners are tempted to call for proportionate across-the-boardexpansion for every profession and occupation to meet burgeoning needs. Medical advances may be shifting workers’ tasksand responsibilities, but these changes are hard to take into account. Forecasters then translate prevalence of disease in thepopulation directly into workforce requirements, even where people in need are not currently receiving services because ofinadequate financing or other access barriers.

similarly hesitant to seek internship tracks and supervisedwork experience preparing them to treat older adults withMH/SU needs.

Policies to Increase Supply of Geriatric MH/SUPersonnel

These and other barriers to recruitment into geriatricMH/SU specialty training can and should be changed. TheIOM committee recommended continuing and expandingpublic funding for training slots and fellowships forstudents undertaking geriatric MH/SU specialization.Equally important is improving job prospects for graduatesof these specialty programs: This field will neither recruitnor retain specialized professionals unless additionaltraining pays off in better jobs. The shift toward parity ofmental health insurance coverage with coverage forphysical illness should improve relative payments andincome for MH/SU specialists treating patients of all ages.More challenging are the negative stereotypes about agingand mental health held by some students who otherwisemight consider specializing in either aging or MH/SUservices; for some prospective trainees, geriatric MH/SUspecialization carries a double stigma. Increased prestigecould accompany increased compensation, but programshighlighting the personal rewards and satisfactions of thesecareers may also be advisable.

Focus on Capacity for Geriatric MH/SU ServicesNevertheless, it is unlikely that all these policies

together could support sufficient inflow into the geriatricMH/SU specialty occupations. Instead, public policy shouldbolster the capacity to meet burgeoning need. A focus oncapacity fits right in to current health services trends:Throughout the health care sector, providers are attemptingto meet needs and demands more effectively at lower costby using resources in innovative ways, and payment policiesare emerging that support coordination and integration ofservices. The IOM committee recommendations entail

• increasing the capacity of all health personnelworking with older adults to identify, refer, and insome cases treat MH/SU conditions;

• increasing the capacity of all specialty MH/SUpersonnel to work effectively with older adults; and

• increasing the capacity of the health care sectorby developing innovative systems of care,combining resources in new ways to meetgeriatric MH/SU needs.

Building the MH/SU capabilities of general healthpersonnel working with older adults is one arm of thisstrategy. Both the education and the scope of practice ofmost health occupations are specified by stateoccupational licensing statutes and regulation. Once

training is completed, personnel are able to provideservices within their occupation’s regulated scope ofpractice. A competency approach is more functional,stressing the knowledge, skills, and abilities (KSAs) aparticular job requires and evaluating workers’ possessionof these KSAs, acquired both through training and on thejob (Rothwell & Lindholm, 1999). Training for healthoccupations generally touches on the needs of specialpopulations and covers areas across each occupation’sscope of practice. However, the IOM committee’s analysisof training requirements found few requirements forMH/SU training focused on care for older adults (IOM,2012). Competencies to address MH/SU needs should begiven more prominence in both initial training andcontinuing education for general health personnelworking with older adults. Such personnel should betrained to recognize and respond appropriately, givenoccupational practice limits, to depression, anxiety,substance abuse, and other MH/SU conditions.

Direct care workers are a special target for suchinitiatives. Many older adults with depression and othertreatable MH/SU conditions receive services for functionaldisabilities in nursing homes, other residential settings, andat home. Direct care workers, who provide the bulk of thehands-on care in these settings, usually receive minimaltraining and are not well compensated. But they are on thefront line of care for these older adults, whose MH/SU needsmay be deprioritized or ignored while more salient medicaland functional needs are addressed. With care systemsstretched to the limit, increasing MH/SU competencies ofdirect care workers could be an effective way to extendcapacity to address some basic MH/SU needs.

Another potential way to expand workforce capacity forgeriatric MH/SU treatment is to equip professionals alreadyproviding MH/SU care to the general population to serveolder adults more effectively. Job-related training andcertification could better prepare MH/SU personnel tounderstand the special issues of treating older adults.Personnel with MH/SU specializations should be expectedto exhibit competencies for treating older adults, animportant and underserved portion of the population withthese conditions.

Why are geriatric MH/SU competencies underdevelopedand underused by the current elder-care workforce andgeneral MH/SU providers? The need is certainly great enough,but health personnel are compensated based on demand forthe services that their regulated scopes of practice enablethem to provide. Many older adults who could benefit fromMH/SU services do not seek them out, either in primary orspecialty care, and services are poorly compensated whenthey are delivered. Thus, a policy agenda to invest in thegeriatric MH/SU competencies of health personnel mustattend to demand shortfalls while building capacity to supplythese services.

Expanding the Capacity to Treat Older Adults With Mental Health and Substance Use Conditions: A Workforce Policy Strategy




Better preparation of nursing home and home healthworkers, for example, will not pay off unless providersreceive a return for employing well-prepared personnel andfor adopting innovative team or consultation approaches touse their skills for MH/SU needs. In addition, workers need areturn on their own investment of time, energy, and othercosts, so MH/SU preparation and certification shouldcommand higher pay. Support for effective training andcertification in geriatric MH/SU expertise will yield littlereturn unless personnel with these competencies aredeployed, valued, and used in the provision of healthservices—in other words, expanded knowledge, skills, and abilities must be used and paid for in practice.

Focus on Innovations to Increase CapacityShortfalls in MH/SU services for the older adult

population could be addressed by redeploying a specialtyand nonspecialty workforce endowed with geriatric MH/SUcompetencies in new delivery models. Substitution amongtypes of personnel in the general MH/SU arena has becomecommonplace: Driven by technological advances in thepsychotropic pharmacopeia and the cost-containmentmandates of managed care organizations, treatment ofMH/SU conditions has increasingly been carried out inprimary care or by nonphysician personnel, with varyingdegrees of oversight by psychiatrists or other physicians(Mojtabai & Olfson, 2008; Reif, Horgan, Torres, & Merrick,2010). Because Medicare does not pay specialists to consultwith and supervise other personnel, these models aredifficult to transfer for the benefit of older adults.

Such innovations as co-location of specialty MH/SUservices with primary care have been shown to increaseolder adults’ engagement in MH/SU treatment (Collins,Hewson, Munger, & Wade, 2010). Although primary care isalready overburdened, investing in the MH/SUcompetencies of the primary care team and increasingMH/SU screening and treatment activities could meetpatients needing such services where they already receivecare. Payment policy must compensate providers for theseintegrated services, in the context of sustaining goodgeriatric primary care (Bachman, Pincus, Houtsinger, &Unutzer, 2006).

The IOM committee also identified delivery systeminnovations that may hold special promise for each of the

target populations with the mostsubstantial gaps in service. (Chapter 4 of thereport offers a more complete discussion ofthe evidence base for these demonstrationsand innovations.) However, as notedpreviously, preparing personnel foremployment in even the most effectiveinnovations will not be enough if thepayment system does not support newways of delivering care.

Older adults aging with severe and persistent mentalillness have special health challenges: The usual multiplechronic conditions associated with older age aremagnified by poor access to primary care (in part becauseof these patients’ reliance on MH/SU providers as theirprimary source of care) and side effects of psychiatrictreatment. Known to have higher rates of diabetes,cardiovascular disease, and conditions associated withsmoking, this population has high medical expenses;improving the management of all their chronicconditions could result in substantial reductions inhospitalization, as well as other savings. Co-location ofprimary care providers in mental health settings is aninnovation designed to coordinate care.

The IOM committee highlighted several effective,evidence-based treatment innovations for this population.Several of these innovations embody the currentwatchwords of system change in general health caredelivery: coordination and team-based care. One employs acommunity mental health nurse along with rehabilitationspecialists to coordinate medical care and help keep clientsin the community. Several meet clients where they live,training building superintendents and other communitypersonnel to alert a care system when clients are havingdifficulty. A community-based innovation engages peervolunteers to work with clients themselves to promotewellness and recovery. All extend the capacity of thetreatment and support system by leveraging competenciesof professionals and enlisting new types of personnel.

Identifying and addressing alcohol misuse in briefinterventions has been trialed for older adults in a programthat builds on the success of the Screening, BriefIntervention, and Referral to Treatment (SBIRT) program, amodel used for working-age adults. It is notable that theservices of SBIRT counselors are eligible for payment byMedicare and Medicaid, in contrast to the situation for otherevidence-based innovations that provide MH/SU services toolder adults in novel ways. However, this model has not yetbeen widely disseminated.

Rural older adults, as well as others who experiencedifficulty leaving home for outpatient visits, could make use oftelehealth innovations. In these approaches, nurses work withpatients by telephone to monitor medication response andprovide supportive counseling. Although such models hold

Unmet MH/SU needs have beenshown to complicate the treatmentof other conditions.



special promise for isolated older adults with MH/SU, theyhave not been tested with this age group.

Older home-care recipients are an especially vulnerablepopulation, with multiple chronic medical and functionalconditions, as well as difficulties in gaining access toambulatory care. Home-care workers with MH/SU traininghave been able to identify and refer clients for furtherevaluation and services, as well as provide some services athome (Gellis & Bruce, 2010). More complete training forfrontline home-care workers, coupled with payment thatrecognizes these increased competencies, could supportfurther implementation.

With more than half of nursing home residentsexperiencing depression, the nursing home should be anespecially apt setting for developing effective approachesto MH/SU care for older adults with multiple chronicconditions. Nursing homes use a psychiatric consultationmodel, but the IOM committee found limited evidence forits effectiveness. Current policy to reduce the use ofpsychotropic drugs to control resident behavior isgenerating innovations that train frontline nursing staffto use other therapeutic interventions (Centers forMedicare & Medicaid Services, 2012). Nursing homepersonnel with greater competence in MH/SU issues andresources to improve this dimension of care could betteraddress the mental health needs of this population.

Policy ImplicationsThe substantive chapters of the IOM (2012) report on

the MH/SU workforce for older adults comprise a valuableresource for all interested in MH/SU needs, workforce, andservices for older adults. Applying a capacity buildingapproach to these background findings generated policystrategies for meeting the MH/SU needs of the growingolder adult population. The IOM committee called formuch-needed initiatives to recruit and train increasednumbers of health workers to specialize in this importantarena of practice, policies to deploy and maintain theseworkers in practice, and policies to monitor and plan forfuture need, demand, and supply of personnel. But beyondthe expected appeal for more specialty personnel, thecommittee recommended expanding and enlisting thecapacities of all health workers who provide care to olderadults, developing their competence to identify, refer, andin some cases treat MH/SU conditions, as well as adaptingthe skills and knowledge of the general MH/SU workforceto serve older adults. Finally, to ensure that expandedcapacities are engaged to meet needs, the committee alsocalled on the agencies that set payment, eligibility forservices, and quality standards to support innovative,evidence-based ways to supply MH/SU services to olderadults. The imperatives of health care cost increases andgrowing unmet need demand no less.

Christine E. Bishop, PhD, is the 2012–2013 Health and AgingPolicy Fellow, Atlantic Philanthropies, and Atran Professor of LaborEconomics, Heller School for Social Policy and Management,Brandeis University. This article is based on the 2012 report of theInstitute of Medicine Committee on the Mental Health Workforcefor Geriatric Populations, of which she was a member, but the viewsare her own. See the original report online at http://www.iom.edu/Reports/2012/ The-Mental-Health-and-Substance-Use-Workforce-for-Older-Adults.aspx, for more extensive detail and evidencesupporting many of the points she makes in this article.

ReferencesBachman, J., Pincus, H. A., Houtsinger, J. K., & Unutzer, J.

(2006). Funding mechanisms for depression caremanagement: Opportunities and challenges. GeneralHospital Psychiatry, 28, 278–288.

Centers for Medicare & Medicaid Services. (2012).Collaborative efforts and technical assistance resources tostrengthen the management of psychotropic medications forvulnerable populations (CMCS Informational Bulletin,August 24). Retrieved from http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-08-24-12.pdf

Collins, C., Hewson,D. L., Munger, R., & Wade, T. (2010, May).Evolving models of behavioral health integration in primarycare. New York: Milbank Memorial Fund. Retrieved fromhttp://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf

Gehi, A., Haas, D., Pipkin, S., & Whooley, M. A. (2005).Depression and medication adherence in outpatients withcoronary heart disease: Findings from the Heart and SoulStudy. Archives of Internal Medicine, 165, 2508–2513.

Gellis, Z. D., & Bruce, M. L. (2010). Problem solving therapyfor subthreshold depression in home healthcare patientswith cardiovascular disease. The American Journal ofGeriatric Psychiatry, 18, 464–474.

Institute of Medicine Committee on the Mental HealthWorkforce for Geriatric Populations. (2012, July). The mentalhealth and substance use workforce for older adults: In whosehands? Washington, DC: The National Academies Press.

Jiang, W., Alexander, J., Christopher, E., Kuchibhatla, M.,Gaulden, L. H., Cuffe, M. S., . . . O’Connor, C. M. (2001).Relationship of depression to increased risk of mortalityand rehospitalization in patients with congestive heartfailure. Archives of Internal Medicine, 161, 1849–1856.

Mojtabai, R., & Olfson, M. (2008). National trends inpsychotherapy by office-based psychiatrists. Archives ofGeneral Psychiatry, 65, 962–970.

Reif, S., Horgan, C., Torres, M., & Merrick, E. (2010). Types ofpractitioners and outpatient visits in a private managedbehavioral health plan. Psychiatric Services, 61, 1066–1068.

Rothwell, W. J., & Lindholm, J. E. (1999). Competencyidentification, modelling and assessment in the USA.International Journal of Training & Development, 3, 90–105.


Although medication interventions to treat problematicbehaviors associated with dementia are routinely sought, nogood alternatives to antipsychotics are currently available.Antipsychotic medications are considered the best option formanaging psychosis or severe behavioral manifestations ofdementia—and, in some cases, they are effective. However,ongoing concern that antipsychotics are used unnecessarilyand excessively, as well as that they impose identified risks,calls for increased efforts to find alternative treatments.

The U.S. Food and Drug Administration (FDA) requires ablack-box warning in antipsychotic labeling due to an increasedrisk of mortality for individuals with dementia. Clinical trialssuggest that for every 100 individuals who receive anantipsychotic in a 10-week to 12-week trial, approximately oneexcess death is associated with exposure to the antipsychotic(Maglione et al., 2011). Other adverse events associated withantipsychotic use in older adults with dementia includesedation, movement disorders, cerebrovascular events(Maglione et al.), and fractures (Rigler et al., 2013). The risks ofantipsychotics create an imperative to limit their use to treatingselected symptoms that do not respond to other interventions.As outlined in the Centers for Medicare & Medicaid Services(2011) regulations, appropriate uses of antipsychoticmedications involve treating unmanageable aggression,psychosis, or other symptoms that cause severe distress orthreaten the safety of either the person with dementia or others.

Although these important criteria should dictateantipsychotic medication use in long-term care and othersettings, increasing evidence suggests that a variety offactors influence their implementation in daily practice. Thepurpose of this article is to provide an overview of keyissues relevant to policymakers related to antipsychoticmedication use in individuals with dementia. This articlealso discusses factors that present important challenges orbarriers to achieving optimal levels of antipsychotic useamong older adults with dementia.

Background of Current IssuesAt the request of Senator Chuck Grassley (R-IA), the Office

of Inspector General of the U.S. Department of Health and

Human Services conducted an evaluation of atypicalantipsychotic use in nursing home residents from January 1,2007, through June 30, 2007. Key findings of the 2011 reportinclude that 14 percent of nursing home residents had aMedicare claim for an atypical antipsychotic (a total cost of$309 million), 83 percent of claims were for off-labelconditions, and 88 percent of off-label prescribing was forpeople with dementia. Of the atypical antipsychoticprescriptions, 22 percent did not meet the Centers forMedicare & Medicaid Services (CMS) standards for appropriateuse in nursing homes (Office of Inspector General, 2011).Notably, the largest number of claims were for quetiapine,which four randomized controlled trials have found to beineffective for treatment of neuropsychiatric symptoms ofdementia (Maglione et al., 2011). As a result of evidencesuggesting overuse of antipsychotics, CMS implemented aninitiative in 2012 to reduce antipsychotic use in nursing homesby 15 percent by the end of that year (Bonner, 2012).

The proportion of nursing home residents who are treated with all types of antipsychotic medication(including older, conventional antipsychotics) isconsiderably higher than 14 percent. A recent analysis of data from a national long-term care pharmacycorporation found that 22 percent of nursing homeresidents received an antipsychotic. That analysis alsofound large variation in antipsychotic use by state, with a rate of 17.2 percent in the lowest-quintilestates compared with 28.1 percent in the highest quintile(Briesacher et al., 2013). This variability reinforces theassertion that antipsychotics are overused in somesituations, because providers in some locations aresuccessfully managing the clinical manifestations ofdementia with fewer antipsychotic drug interventions.

Despite evidence that antipsychotics may be usedunnecessarily or improperly, a considerable number ofindividuals with dementia are receiving appropriatetreatment by CMS standards. Alternative drug treatmentsgenerally lack evidence regarding their safety and efficacy(Jeste et al., 2008), making antipsychotics the best of thelimited choices in dementia care. Antipsychotics do have

Antipsychotic Use in Individuals With Dementia: An Overview for PolicymakersRyan M. Carnahan • Michael W. Kelly • Marianne Smith

IntroductionAntipsychotic medication use in individuals with dementia is a common practice that has been the subject

of much attention and controversy. The Omnibus Reconciliation Act of 1987, which legislated nursing home reform,addressed risks and issues associated with physical and chemical restraints—particularly, excessive use of antipsychoticmedications—among nursing home residents. Although these legislative restrictions initially resulted in reduced reliance onantipsychotic medications in long-term care settings, antipsychotic use rates have since increased to levels within the range ofthose observed prior to the Omnibus Reconciliation Act (Briesacher, Tjia, Field, Peterson, & Gurwitz, 2013).


Antipsychotic Use in Individuals With Dementia: An Overview for Policymakers

safety issues, but evidence also supports the efficacy of several antipsychotics for individuals with dementia(Maglione et al., 2011). Those who respond positively to antipsychotics have a higher risk of relapse whenantipsychotics are discontinued, suggesting that someindividuals may benefit from longer-term treatment(Devanand et al., 2012).

Proponents of practice-improvement efforts believe thatbetter evaluation and treatment of potential causes (e.g.,pain or medical conditions), as well as use of behavioral orenvironmental management strategies (i.e., nonpharmacologicor nondrug interventions), can reduce unnecessaryantipsychotic use. Another goal is to prevent the use ofantipsychotics to sedate a person simply to make caregivingeasier, when the intensity and type of behavioral symptoms do not actually justify antipsychotic use. However, few involvedin dementia care believe that antipsychotics should never beused, despite their risks. The manifestations of dementia maycreate safety issues that compromise quality of life for peopleand their caregivers, and antipsychotics may help. Theoverarching aim is to ensure that nondrug care approaches and treatment options have been fully explored beforeresorting to antipsychotic medications.

Nonpharmacologic ManagementAntipsychotic treatment is routinely focused

on noncognitive symptoms of dementia, which areinterchangeably called neuropsychiatric symptoms,behavioral and psychiatric symptoms, and problematic,disruptive, or challenging behaviors. Occurring in anestimated 90 percent of all people with dementia,behavioral and psychiatric symptoms range from being mild to severe in intensity, in frequency, and in causingdistress to the individuals and those around them.Dementia-care principles aimed at enhancing function,comfort, symptom control, and quality of life emphasizedetection, management, and treatment of noncognitiveproblematic behaviors as a key part of dementia care(Lyketsos et al., 2006). Stepwise assessment of problematicbehaviors involves characterizing the specific behavioral orpsychiatric disturbance, differentiating the problem fromother issues, evaluating and treating contributing andcausal factors, and using nondrug interventions tailored tothe individual needs and issues of the person with dementia.Medication interventions are recommended only whennondrug approaches have failed or when the level of distress,danger, or disability caused by the problem behavior (i.e.,CMS criteria) supports their use (Lyketsos et al.).

Nondrug interventions and treatments are oftengrouped into broad categories, such as addressing unmet needs, modifying the social or physical environment,engaging the person in pleasant and meaningful activities,changing activity demands, and providing cognitive

stimulation and support. Common criticisms include thefact that few nondrug treatments have been evaluatedusing double-blind, randomized clinical trials. The smallnumber of studies in each category, small sample sizes,inconsistent definitions of outcomes and terms (such asagitation), and other methodological variations amongstudies impede interpretation using systematic reviews and meta-analyses. Livingston, Johnston, Katona, Paton, and Lyketsos (2005) have concluded, however, that “lack ofevidence of efficacy does not mean lack of efficacy” (p. 2017).

Building a stronger foundation of scientific evidence for nondrug interventions in dementia care relies on several factors. Foremost, increased funding for nondrugintervention research is needed to promote both the quality of studies and the growth of scientific evidence.Innovative, high-quality research designs and analyticmethods are needed to evaluate the individualized,multimodal approaches that are increasingly recognized as being most successful in reducing and preventingproblematic behaviors. Furthermore, the use of gradingsystems that assign the highest ratings to randomized,controlled trials should be thoughtfully applied whenassessing behavioral interventions that may be betterevaluated using alternative research designs. In short,nondrug interventions are essential components ofdementia care that demand greater emphasis in research, as well as in both clinical practice and care settings.

Consent and Shared Decision Making forAntipsychotic Use

Appropriate prescribing is the most important meansto reduce the risks associated with using antipsychotics in individuals with dementia. Another way to mitigate the medicolegal risk is to provide information on risksand benefits and seek written informed consent prior totreatment. All discussions of risk in this population arecomplicated by the impaired decision-making capacity of individuals with dementia. As with other care andtreatment decisions, individuals with compromiseddecision-making capacity should be involved to theappropriate degree, and their advance directives shouldbe followed. Guardians, medical-decision surrogates, ordesignated family members are often involved in caredecisions and may provide informed consent forantipsychotic medication use. Furthermore, familymembers are also often directly involved in their relative’scare and can provide important information about theindividual’s wishes (Recupero & Rainey, 2007). In mostinstances where impaired individuals do not haveidentified surrogates or relatives, health care providerswill need to act as de facto decision makers and proceedin the best interests of the patient (American MedicalDirectors Association, 2003).



The Improving Dementia Care Treatment for OlderAdults Act of 2012 was introduced in the U.S. Senate as an amendment to title XVIII (Medicare) of the SocialSecurity Act. The amendment specifically addressed use ofantipsychotics in skilled nursing facilities by implementingprescriber education programs, collecting information onthe use of antipsychotics in these facilities, and requiringthat informed consent is obtained before antipsychotics are prescribed. The amendment was referred to committeein the 112th Congress and has not yet been reintroduced.

Failure of the amendment provides an opportunity toreassess its aims and clarify important policy issues. Questionsto resolve include the following: Should policies coverindividuals outside of nursing facilities? Who should beresponsible for explaining risk and obtaining consent? What isthe expectation in case of emergency use? Might healthcarecosts increase if these agents are unavailable and thealternative is hospitalization? How should individuals withdementia who lack family or appointed medical surrogates be protected? Until legislation is enacted, providers will need to continue to prescribe these medications by followingstate regulations and the rules of good clinical practice.

CMS Antipsychotic Use Quality MeasureCMS recently revised its nursing home quality measures,

which assess rates of antipsychotic use among facilityresidents without specific diagnoses that justify antipsychoticuse. The previous metric excluded individuals with specificdisorders—including schizophrenia, Tourette’s syndrome,Huntington’s disease, bipolar disorder, hallucinations, anddelusions—that are appropriately treated with antipsychoticmedications (CMS, 2012). Two controversial aspects of thenew quality measure relate to bipolar disorder andappropriate use of antipsychotics in people with dementia.

People with bipolar disorder are no longer excludedfrom the pool of residents used to calculate the qualitymeasure, even though several antipsychotics have FDA-approved indications for treating this disorder (Maglione etal., 2011). Bipolar disorder was removed from the exclusioncriteria because of evidence that a diagnosis could berecorded on Minimum Data Set (MDS) assessments (used tocalculate the quality measure) in the absence of a providerdiagnosis, thus introducing the opportunity to abuse thesystem. The cited justification for this change noted that 28percent of residents were identified as having bipolardisorder on the MDS at some time after the admissionassessment, suggesting a new diagnosis while in thenursing home. This finding raises important questions aboutdiagnostic accuracy, because bipolar disorder rarely has alate-life onset. Although the change in the quality metricmay reduce such inaccuracies, residents who have alegitimate diagnosis of bipolar disorder and are justifiablyreceiving an antipsychotic for that condition will beincluded in calculations estimating inappropriate use.

A related concern is that the quality measure gives noattention to whether the use of the antipsychotic is appropriateor inappropriate by CMS standards, based on the types andseverity of symptoms that a resident with dementia hasexhibited (CMS, 2013). The overarching concern about theinclusion of residents with bipolar disorder, as well as thosewith dementia symptoms appropriately treated with anantipsychotic, is that facilities who accept these residents willbe punished with poor-quality metrics. Compassionatefacilities that accept individuals with severe behavioral issues or specific mental disorders will receive lower quality ratingsregarding antipsychotic use. Although potential inaccuracies in MDS documentation provide a sound rationale for revisingthe quality measure, unintended adverse consequences ofthese changes must be carefully monitored. Worst-casescenarios may include indefinite hospitalizations of peoplewho benefit from antipsychotics because their admission to a nursing home would hurt quality metrics, or the closing offacilities that accept the most seriously ill and impairedresidents due to adverse consequences of poor-quality metrics.

Challenges With Implementation of BestPractices

Reducing use of antipsychotic medications to treatproblematic behaviors in dementia relies on improving daily care practices and adapting the physical and socialenvironment to best accommodate individuals withdementia. In many long-term care settings, high staffturnover rates interfere with quality dementia care bycontributing to staff shortages in general, shortage of staffwith adequate training in dementia care, and inconsistentleadership to advance changes. Organizational culture iscritically important to adopting routine use of nondrugapproaches and interventions instead of seekingantipsychotic medications as the first-line intervention for problematic behaviors. Person-centered cultures thatsupport providers of daily care in recognizing and addressingproblematic behaviors are the gold standard for dementiacare. Continued movement away from task-oriented andillness-oriented care environments—which often reflect aprescribing culture—is essential, but also difficult to achievein the absence of strong and consistent leadership.

Another important consideration in reducing use ofantipsychotic medications is the time needed to adequatelyassess individualized needs, taper medications, and evaluateoutcomes. Abrupt changes in medications may poseunnecessary risks to patients with dementia and potentiallyburden health systems. Thoughtful assessment of thefrequency, intensity, and level of distress or threat of aparticular behavior is essential, followed by gradual dosereduction and systematic outcome assessments.

The CMS goal of reducing antipsychotic medication use in nursing homes by 15 percent in 8 months included anaggressive timeline for change. This type of change requires



considerable coordination by leaders, buy-in from careproviders and prescribers, education and resources tosupport optimal practices, and information sharing among allstakeholders. Even after the foundation is laid, implementingnew practices takes time, as does careful tapering anddiscontinuation of antipsychotics in individual residents.Although the 15 percent goal has not been reached,reductions in antipsychotic use to date are encouraging.

ConclusionEfforts to improve dementia care will not be successful

overnight. Policymakers need to be cognizant of thecomplexity of the issue when developing policies meant toaffect antipsychotic use. The idea that antipsychotics shouldnever be used in individuals with dementia is unrealistic givencurrent treatment options. Coordinated efforts to improvecare for people with dementia should be applauded andcontinued, with the goal of creating enduring culture changethat limits the unnecessary use of antipsychotics whilerecognizing that antipsychotics are sometimes appropriatefor managing symptoms in individuals with dementia.

Ryan M. Carnahan, PharmD, MS, is a clinical associateprofessor of epidemiology at the University of Iowa College ofPublic Health. Michael W. Kelly, PharmD, MS, is a clinicalprofessor of pharmacy practice and science, as well as associatedean for professional education at the University of Iowa Collegeof Pharmacy. Marianne Smith, PhD, RN, is an associate professorof nursing at the University of Iowa College of Nursing.

AcknowledgmentThis work was supported by the Agency for Healthcare

Research and Quality (AHRQ), grant R18HS019355. Thecontent is solely the responsibility of the authors and doesnot necessarily represent the views of AHRQ.

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Rigler, S. K., Shireman, T. I., Cook-Wiens, G. J., Ellerbeck, E. F.,Whittle, J. C., Mehr, D. R., & Mahnken, J. D. (2013). Fracturerisk in nursing home residents initiating antipsychoticmedications. Journal of the American Geriatrics Society, 61, 715–722.


Because suicide rates are highest among men ages 65and older, the prevention of suicide in later life is a centralobjective of this strategy (Conwell, Duberstein, & Caine,2002; Conwell & Thompson, 2008; Kaplan, Huguet,McFarland, & Mandle, 2012). Older adults comprised 13.0percent of the U.S. population but accounted for 15.6percent of all suicides. There were 5,994 suicides amongadults ages 65 and older in 2010, including 5,035 men and959 women (Centers for Disease Control and Prevention,2010). Moreover, as seen inFigure 1, suicide rates per100,000 increased withage—from 22.4 percentfor men ages 65 to 69 to47.3 percent for men ages85 and older, the highestrate for any age group(Crosby, Ortega, & Stevens,2011). Across the age span,the male-to-female suicidedeath ratio is 4 to 1, but inolder age it goes up tonearly 12 to 1 (Kaplan,Huguet, et al., 2012). Onereason that the suiciderates are so much higher inlater life is that theattempts are more lethalcompared with those inyounger adults. Olderpeople, older White men inparticular, more oftencommit suicide with self-inflicted gunshots. As such,although suicide ranks asthe 12th leading cause of

death among older adults, it is considered to be the leadingcause of preventable death in this population (Kaplan,Adamek, & Johnson, 1994).

Risk FactorsConwell and colleagues (2002) contended that later-life

suicide is a complex behavior, driven by multiple determinantsworking both independently and in combination. The risks ofcommitting suicide among older adults involve psychological,

Suicide in Later Life: The Role of Risk Factors, Firearm Policy, and Primary Care Physicians

Mark S. Kaplan • William Coryell

Although much of the recent gun debate has focused on mass shootings and assault weapons, one fact that remains ignoredis that more Americans die each year from self-inflicted gunshots than from homicides and mass shootings combined (Tavernise,2013). According to the Centers for Disease Control and Prevention (Murphy, Xu, & Kochanek, 2013), suicide is the 10th leadingcause of death and results in more than 38,000 suicides each year in the United States. Suicide deaths outnumbered homicides ata rate of almost two to one. The Surgeon General of the United States proclaimed suicide as a prominent public health policy issuein 2001 and developed a national strategy for suicide prevention (U.S. Public Health Service, 2001).

Figure 1. Overall suicide rates and percentage of suicides involving firearms,by gender and age.

Source: Centers for Disease Control and Prevention (2010).

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physical, and social factors. Moreover, thesedeterminants vary with age, as well as withgender, race, and socioeconomic status—inother words, what drives a 70-year-old elder anda 90-year-old elder to suicide probably differs.What also distinguishes suicide among elders isthe relative paucity of forewarnings. Older adultsare not as likely to express ideation, engage infailed attempts, or inform others of their suicidalplans as younger people. Compared withyounger suicide decedents, older adults engagein more planning, have greater resolve, and usemore violent and deadly methods to commit suicide.

According to the National Institute of Mental Health(2003), psychiatric disorders are present in up to 90 percentof all elder suicides, with affective disorder as the mostcommon psychopathology. For elders, the rates ofdepression are higher relative to younger suicides and thetype of depression found in the majority of elder suicides isusually a first episode uncomplicated by psychoses or othercomorbid psychiatric disorders—the most treatable type oflate-life depression (Pearson & Brown, 2000). Alcohol andother substance use disorders are present in a smallerproportion of completed elder suicides, followed byschizophrenia and anxiety disorders (Conwell et al., 1996; Hooper et al., 2012).

Elder suicides also have been associated with distinctpersonality traits, including higher levels of neuroticism andlower levels of openness to experience (Conwell et al., 1996).Kaplan, Adamek, and Rhoades (1998) added that eldersuicide has been associated with conflicts and stress ininterpersonal relationships. Another psychological riskfactor that may contribute to suicide behavior in olderadults is hopelessness—a set of negative and a lack ofpositive beliefs about the future (Pearson & Brown, 2000).

Furthermore, older suicide victims are more likely thanyounger suicide decedents to experience a physical illness(Conwell et al., 1996). Although elder suicides have not beenclearly linked with one type of disease or another (e.g.,suicide rates among older individuals with cancer are notstatistically different from rates for those with heart disease),the presence of any type of serious physical illness andassociated functional impairment contributes to suicide in almost 70 percent of victims over 60 years of age. Someassociations have been made between elder suicide andneuronal changes, such as reduced serotonergic systembinding and increased neurofibrillary pathology (Mann,1998; Rubio et al., 2001).

Following on this line of thinking, Luscomb, Clum, andPatsiokas (1980) and Conwell and colleagues (2002) havesuggested that stressful life events cluster in the weeks andmonths before suicide attempts in elders, and that physicalfunctioning and other losses are the most common stressorsin older adults who end their own lives. Family discord,

isolation, bereavement, and widowhood have beenassociated with elder suicide as well (Turvey et al., 2002).

All told, older adults in general (and those at risk forsuicide in particular) tend to be less healthy, and theassociation between physical illnesses and suicide in laterlife could be partly moderated by depression (physicalillness can cause depression, and depression increases riskfor suicide). In addition, older adults who commit suicide areless likely to verbalize their intent and are more likely to livealone and, therefore, are less likely to be found in sufficienttime to be rescued. In contrast to older adults, youngersuicide decedents tend to experience more financial issuesand problems with intimate partners (Kaplan, McFarland,Huguet, & Valenstein, 2012).

Firearms and Elder SuicideHaving documented the importance of these individual-

level psychological, physical, and social risk factors, we nowturn our attention to the role of firearms. The method usedmost frequently among elder suicides involves firearms—usually handguns—and, of all methods of suicide, thoseinvolving firearms are most likely to result in death (Kaplanet al., 1994; Kaplan, Adamek, Geling, & Calderon, 1997;Miller, Azrael, & Barber, 2012). Conwell and colleagues(2002) reported that more than 70 percent of elders whocommitted suicide used guns.

In 2012, Kaplan, Huguet, and colleagues conducted acomprehensive examination of risk factors and precipitatingcircumstances associated with the choice of firearms as asuicide method among men ages 65 years and older. Theyfound that between 2003 and 2007, nearly 80 percent of4,338 older male suicide decedents used firearms, and thesemen were mostly White (95.8%), married (52.3%), and fromSouthern states (60.1%).

The researchers reported that physical illness was one ofthe more salient precipitants of late-life suicide involvingfirearms (Kaplan, Huguet, et al., 2012). They also found thatonly half of the individuals presented depressivesymptomatology. Contrary to existing literature that placesthe depression rate as high as 90 percent, their findingssuggest that depression among older adults, by itself, doesnot lead to suicides as much as it may have a moderating

Serious physical illness and associatedfunctional impairment contributes tosuicide in almost 70 percent of victimsover 60 years of age.



effect, adding to the despair brought on by physical ailment,disease, and disability.

Their findings also confirmed that the decision tocommit suicide resulted from a complex interaction of these individual characteristics and contextual factors. In particular, Kaplan, Huguet, and colleagues (2012)determined that one of the most salient predictors wasfirearm availability. Their analysis showed that the risk ofsuicide by firearms varies significantly by gun ownership,geographic region, and level of rurality, and the likelihood of using a firearm is highly correlated with the prevalence ofguns. In short, the prevalence of gun ownership and accessto guns appears to play a role in fashioning geographicdifferentials in firearm-related suicide mortality. Forexample, after adjusting for age, marital status, education,and metropolitan status, data show that living in the eastsouth central and west south central divisions (the so-calledDeep South) of the United States seems to exert a stronginfluence on the likelihood of using firearms to commitsuicide (Kaplan & Geling, 1990).

Relative to other fixed factors (e.g., age or gender) notresponsive to policy or programmatic efforts aimed atreducing suicide risk, increasing evidence shows that guncontrol laws reduce the overall suicide rate (Clarke & Lester,1989; Miller et al., 2012). Clark (1992) went as far as tosuggest that homicide and suicide rates in the United Statesmight be expected to drop as much as 25 percent if guncontrol legislation was enacted. For example, Ludwig andCook (2000) examined whether implementation of theBrady Handgun Violence Prevention Act in 1994 wasassociated with changes in firearm-specific homicide andsuicide rates in the general adult and older populations inthe United States. In particular, the Brady Act required thatlicensed firearm dealers observe a waiting period andinitiate a background check before selling a handgun.

States that already had this legislation constituted thecontrol group, whereas states newly instituting the legislationserved as the experimental condition. Changes in rates ofhomicide and suicide in experimental and control states werenot significantly different, except for firearm suicides amongpeople age 55 years or older, which showed a significantreduction in the intervention states. Consistent with theobservation that older male suicides were more likely thancontrols to have purchased the gun used to kill themselves inthe week preceding death, the effect of the Brady legislationwas much stronger in states that had instituted waitingperiods and background checks than in states that hadchanged only background check requirements (Ludwig &Cook, 2000). In the United States, where older men are at farhigher risk than other groups and more than 75 percent ofsuicide decedents die of self-inflicted gunshot wounds, thesefindings are particularly notable.

Arguably, strategies aimed at reducing suicide throughfirearm policy must start with firearm availability and

access. Moreover, given regional differences in suchpolicies, efforts should account for local norms, values,expectations, and coping strategies (Corin, 1994). Anyefforts to change public perception of firearms and theirutility through educational campaigns (Karlson &Hargarten, 1997) will require serious consideration of thecultural processes that have historically undermined publichealth campaigns aimed at reducing firearm-related injuryand deaths. In some respects, these efforts cannot beginsoon enough. Mertens and Sorenson (2012) documentedrecent efforts by gun manufacturers to develop firearmsspecifically for older adults, such as a handgun with asqueeze-ball trigger that is arguably easier to use forsomeone with severe arthritis or another physical malady.

The Role of Primary Care PhysiciansGiven that more than 70 percent of older suicides

visited their primary care physician within a month of theirsuicide and a third within a week, primary care physiciansplay a crucial role in suicide assessment and prevention(Hooper et al., 2012; Kaplan, McFarland, et al., 2012; NationalInstitute of Mental Health [NIMH], 2003). Moreover, incontrast to younger adults, of whom 25 percent to 30percent were under the care of a mental health professional at the time of their death, virtually none of these elderlypatients had sought mental health services.

Several reasons may explain the failure to recognize andadequately treat older adults at risk for suicide who presentin a primary care setting. On one hand, older patients maynot provide accurate or genuine information about theiraffective state and thoughts, intentions, and deliberateplans to commit suicide. Even when asked about how theyfeel, older depressed adults, especially men, are less likely toreport feeling down or to endorse depressive symptomsand suicidal ideology (Allen-Burge, Storandt, Kinscherf, &Rubin, 1994; Gallo, Anthony, & Muthén, 1994).

On the other hand, primary care physicians tend tospend less time with older patients than they do withyounger patients, and they are more likely to focus onphysical problems to the exclusion of psychologicalcomorbidity (German, Shapiro, & Skinner, 1985; Keeler,Solomon, Beck, Mendenhall, & Kane, 1982). Curiously,despite being the most sought after health care providersamong all individuals with depression in the United States,primary care doctors typically neither recognize noradequately treat depression among any age group (Sturm &Wells, 1995). In fact, some physicians avoid diagnosing amood disorder, even when recognized, both to avoidstigmatizing the patient and to avoid reimbursementproblems (Rost, Smith, Matthews, & Guise, 1994). Physiciansalso may have a more difficult time detecting affectivesyndromes in older adults because these syndromes may be milder and further complicated by comorbid medicalillnesses and prescription medications. Still, even if primary



care providers recognize psychiatric symptoms and suicidalideation, treatment most likely will be inappropriate orinadequate (Kaplan, McFarland, et al., 2012).

In an effort to illuminate physician practices concerningsuicide detection and assessment, Kaplan and colleagues(1998) reported that a sizeable proportion (42%) of primarycare physicians never even asked depressed patients or theirfamily members whether they had access to a firearm—although they found that physicians were more likely to askabout medication misuse among older depressed andsuicidal patients. Those physicians who actively assessedfirearm availability were more likely to have completedtraining in suicide risk assessment, to have obtainedexpertise in geriatric mental health, and to display higherconfidence in diagnosing depression (Kaplan et al., 1998).Although all physicians are in a unique position to helpprevent elder suicide, those who recognize the “risks,predisposition, clues, and signs of imminent suicide”(Frierson, 1991, as cited in Kaplan et al., 1998, p. 63) are the most effective.

In another study, Hooper and colleagues (2012) foundthat only 36 percent of the physician sample was capable of conducting a suicide risk assessment when treating apatient presenting with major depression. Vannoy, Tai-Seale,Duberstein, Eaton, and Cook (2011) added that suicide-related communications among primary care physicianswere inadequate, observing how physicians consistentlymissed opportunities to provide therapeutic empathy orfollow an established best-practice protocol even whensuicidal ideation was evident.

To the extent that suicide prevention relies on timelyand effective detection and treatment of mental disorders,preventive interventions must be targeted at identifyingand evaluating patients’ suicidal thoughts and possession offirearms. Given that a large proportion of the population atrisk is seen in these settings, primary care is the mostobvious venue to develop and implement preventiveinterventions. As such, primary care physicians ought to beaware of and use published depression guidelines forpatient care. Primary care clinics also should consider usinga screening instrument for depression and suicideassessment with all patients, especially older adults and

other patients with comorbid medicalconditions. Along these lines, primary careclinics should consider integrating behavioralhealth care providers (e.g., clinicalpsychologists, clinical mental healthcounselors, social workers, psychiatric nurses) into their practices.

This sort of integrated model of care hasbeen shown to reduce suicidal ideation amongolder patients and prevent acts of suicide. Inparticular, the Prevention of Suicide in PrimaryCare Elderly: Collaborative Trial (PROSPECT)

compared usual care by primary care providers withalgorithm-driven antidepressant treatment; interpersonalpsychotherapy when indicated; physician, patient, and familyeducation about the illness; and care management by adepression specialist (e.g., a social worker, nurse, orpsychologist). In a sample of 598 subjects older than 60 yearswho had depression, Bruce and colleagues (2004) found thatrates of suicidal ideation declined significantly faster in theintervention than in the comparison condition—from 29.4percent to 16.5 percent (a 12.9% decline) in the interventiongroup compared with 20.1 percent to 17.1 percent (a 3.0%decline) in usual care (p = .01).

DiscussionAlthough expanding models in which primary care

physicians work with other providers to help identify olderadults at risk for suicide seems like a reasonable alternative,the dissemination of this sort of programmatic effort is likelyto face considerable challenges. Efforts to expand suchempirically based programs often fall short becauseorganizational and contextual factors that were not asrelevant in the more controlled settings in which the ideaswere originally developed and tested become salient asthese efforts move toward widespread translation (Kimberly& Cook, 2008). In this case, health care system administratorsmay not place a priority on training physicians and otherstaff to address a comparatively low-incident event, andlocal cultures in which many of these health care providersare embedded may not support any programmatic effortthat could easily be construed either as gun control inparticular or as a public infringement on the provider-patient relationship more generally.

In fact, evidence of the latter is compelling. The LawCenter to Prevent Gun Violence (2013) reported that asmany as seven state legislatures recently have consideredlegislation that would prohibit doctors from askingpatients about gun ownership, including when suchqueries might be relevant to a patient’s medical care orsafety. Although none of these bills have been enacted,they demonstrate the sort of chilling effect that a largerinterest may exert on the discrete act of a physicianseeking to help an older adult at risk for suicide. This effect

Primary care physicians are morelikely to focus on physical problemsto the exclusion of psychologicalcomorbidity.



is not imagined; the Patient Protection and AffordableCare Act (2010) includes language that prohibits insurers,employers, and the U.S. Department of Health and HumanServices (HHS) from asking about gun ownership in manyinstances, and it prohibits HHS from collecting such data.

The American Bar Association (2012) recently has takena position against such medical gag laws and passed thefollowing resolution:

For medical practitioners to meet their preventivecare and safety counseling responsibilities, theymust be able to discuss a broad range of topics withtheir patients related to known risk factors. Thisunfettered access allows doctors to adequatelyassess and address these factors with their patients.Risk factors that may be discussed vary dependingon the age of the patient, but for adults ofteninclude alcohol consumption, illicit drug use,smoking, diet, and exercise; pediatricians oftendiscuss wearing seat belts and bicycle helmets, thepotential dangers of backyard swimming pools, andthe need to securely store household cleaners andtoxins. Firearms in the home are another known riskfactor that doctors may choose to discuss with theirpatients or the parents of young patients. (p. 10)

In April 2013, Senators Tom Harkin and LamarAlexander introduced the bipartisan Mental HealthAwareness and Improvement Act of 2013. This federal actwould establish a suicide prevention technical assistancecenter, as well as provide information and training forsuicide prevention, surveillance, and interventionstrategies for all ages—particularly among groups at highrisk for suicide, such as older adults. Curiously, althoughmany associations already have endorsed this act, wefound no definitive proclamation from any professionalhealth provider constituency highlighting the need tosupport efforts to address elder suicide within primary caresettings and specifically calling on physicians to considerthe associations between older age, physical health,feeling down, thinking about suicide, and owning a gun.These issues will only become more urgent with the sharpincrease of the 65-plus population in the United States incoming years.

Mark S. Kaplan, DrPH, is a professor of community health,College of Urban & Public Affairs, School of Community Health,Portland State University. William Coryell, MD, is a professor ofpsychiatry, Carver College of Medicine, University of Iowa.

AcknowledgmentWe thank Dr. Nathalie Huguet for her assistance in the

preparation of this article.

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must apply the PASRR process to all new admissions andresidents regardless of age or payer source. The first step,called a level I screen, involves a basic psychiatric screening to identify people who may have mental illness, mentalretardation, or both. In addition, the screen is expected toidentify functional limitations. The level I screen must beconducted within 30 days of a new admission or in responseto a significant change in a current resident’s clinical status.However, individuals who have a primary diagnosis ofAlzheimer’s disease, delirium, or a related neurocognitivedisorder; people admitted directly from a hospital for post-acute care; or individuals who are likely to require less than 30 days of nursing facility care, including admissions relatedto emergencies or respite, are exempt from the screeningservices (Nursing Home Reform Act, 1987; PASRR TechnicalAssistance Center, 2010).

The second step of the PASRR process, referred to as alevel II evaluation, is designed to confirm or reject a positivelevel I screen. When an evaluation confirms a seriouspsychiatric condition and major functional limitation, theevaluator details the need for specialized services and lessintensive nursing facility services, and provides a descriptionof the supports needed for the patient to return to a lessrestrictive setting. The PASRR evaluation is sent to the stateauthority and then used by the nursing facility to developan individual treatment plan. The treatment plan is executedin one of three ways. If the nursing facility can providespecialized and less intensive therapeutic services, thepatient remains a resident at the facility. If the personcontinues to require medical and psychiatric care but thefacility cannot provide specialized services, then the patientmust be diverted to another facility. If a person no longerwarrants nursing care but still needs psychiatric care, theperson should be discharged to the most appropriate, leastrestrictive setting available to receive specialized and otherless intensive services (Nursing Home Reform Act 1987,PASRR Technical Assistance Center, 2010).

Specialized services refer to a level of care necessary totreat an acute phase of a psychiatric condition (KentuckyState Mental Health/Mental Retardation Services, 2004;North Carolina Department of Health & Human Services,2005). Specialized services must be provided by a licensedor certified practitioner and must lead to demonstrableimprovements in the resident’s psychiatric status (Molinariet al., 2010). Specialized services consist of activities andtherapies typically provided in an inpatient psychiatricsetting, such as psychological testing, individual or grouppsychotherapy, and medication management. Less intensiveservices typically include activity therapy and supportivecounseling. Each state is charged with approving the menuof specialized services that can be included in an individual’splan of care as developed by the nursing facility (Linkins,Lucca, Housman, & Smith, 2006a).

Administratively, designated state mental health andstate mental retardation authorities are responsible forensuring that PASRR screens and evaluations are conductedin accordance with federal regulations (Kentucky StateMental Health/Mental Retardation Services, 2004; Timmel,2005). These state authorities can either implement the two-step PASRR process directly or contract with an independentorganization and monitor its efforts. The designated stateMedicaid agency is responsible for ensuring that statemental health and state mental retardation authorities fulfillthe statutory responsibilities. All of the state agencies andindividual nursing facilities are subject to audits andcompliance reviews by another designated state authority,such as an inspector general. Failure of any these agenciesto uphold their responsibilities could lead to actions asspecified under section 1904 of the NHRA.

Has PASRR Been Effective?In 2006, Linkins and colleagues found that PASRR

increased the identification (and diversion) of nursingfacility residents with psychiatric conditions and that level IIevaluations often validated positive level I screens. Yet, theyalso reported that psychiatric medication therapy remainedthe primary form of specialized psychiatric treatment, withfew efforts to provide nonpharmacological specializedservices counseling (Linkins, Lucca, Housman, & Smith,2006b). Li (2010) echoed these findings and concluded thatthe overall availability of nonpharmacological specializedand less intensive services had not improved since theenactment of the NHRA in 1987; the lack of specializedservices was most problematic in small and rural facilities.

Upon request, the Division of Mental Health and DisabilityServices of the Iowa Department of Human Services providedDisability Rights Iowa with information about the screeningsand evaluations that the state’s PASRR contracting agency hadcompleted during the past 2 fiscal years. Disability Rights Iowaestimated that from July to December 2012, the contractorinitiated slightly more than 11,000 Web-based level I screensand exempted slightly more than 6,400 from further review.Among the individuals who did complete a level I screenduring this period, nearly 13 percent were referred for a level IIevaluation (Ascend Management Innovations, 2012b).

Among those completing the level II evaluation, 52percent were approved to receive specialized services. Themost common recommendation was having a psychiatristreview the prescription medication protocol. Individualtherapy was recommended in 24 percent of these cases,psychological testing was recommended in 9 percent of the cases, and group therapy was recommended in 4percent of the cases. Less intensive specialized serviceswere recommended more frequently. The most commonspecialized services recommended, for more than 9 out of 10 residents, was supportive counseling with staff (i.e.,


Perspectives on the Pre-Admission Screening and Annual Resident Review Process: Why Can’t This Program Just Grow Up? •Continued from page 1


Perspectives on the Pre-Admission Screening and Annual Resident Review Process: Why Can’t This Program Just Grow Up?

talking with nonqualified mental health providers). Ongoingpsychiatric prescription review was recommended forslightly more than half of the residents, as was participationin social and recreational activities. Interestingly, efforts to prepare a return to the community were recommended for less than 25 percent of the residents (AscendManagement Innovations, 2012a). It was not apparent why many residents with psychiatric conditions did notreceive a recommendation for specialized services and why they were not encouraged to return to the community.It also was not apparent if any state authority approvedseparate payment for specialized services or monitoredpatient outcomes.

In an effort to better understand why PASRR appears tohave fallen short in linking individuals with psychiatricneeds to nonpharmacological specialized services, DisabilityRights Iowa conducted in-depth interviews with designatedPASRR staff from a representative sample of 30 nursingfacilities located across central Iowa. When asked about theprovision of nonpharmacological specialized services, 23 ofthe coordinators indicated that residents with a specializedservice need participated in group therapy and 14respondents reported that residents received individualcounseling—although the majority of PASRR staff indicatedthat these services were not provided by a licensedbehavioral health provider, and thus, do not actually qualifyas specialized services. Fifteen of the staff indicated thattheir facility contracted with a consulting behavioral healthfirm to provide specialized services, but they did not keeptrack of what these entailed.

Back to the Future?Prescription medication therapy has remained the de

facto form of specialized service delivery for nursing facilityresidents with mental illness, same as it ever was. Molinariand colleagues (2010, 2011) determined that as many as 85percent of newly admitted nursing home residents wereplaced on some psychoactive medication within 3 monthsof their admission and, alarmingly, most of these residentshad neither a diagnosed psychiatric condition nor any otherevidence of psychiatric history. They also discovered that asmany as 15 percent of the nursing home residents includedin their sample were taking four or more psychoactivemedications. In Iowa, the designated PASRR staff confirmedthat medications were the most common specializedservices being delivered to people with psychiatricconditions, and 29 of the 30 respondents reported thatpsychiatric medications were being prescribed to residentswho did not even complete the PASRR level I screen or levelII evaluation.

In response to the growing concern about the use ofantipsychotics, the Department of Health and HumanServices, Office of Inspector General (2011), issued a reportdocumenting that nearly 90 percent of all atypical

antipsychotic drug prescriptions being issued to nursingfacility residents violated one or more federal laws. InNovember 2011, the Senate Special Committee on Agingheld a hearing that highlighted the long-term nature of this problem (Overprescribed, 2011).

Staff Engagement and Oversight In Iowa, only 24 of the 30 interviewees reported that

they and other nursing facility staff who monitor the PASRRprocess had completed PASRR-specific training in the past 2 years. Interestingly, correlations among those completingPASRR training and their familiarity with the PASRR processin Iowa were modest. Although 25 of the 30 PASRR staffknew that a positive level I PASRR screen triggers a level IIPASRR evaluation, only 17 were familiar with the online levelI screening process that the state contractor used. SomePASRR staff reported that their facility had never completeda level II evaluation nor ever met anyone representing thecontracting agency. In regard to resident reviews, 14 of thePASRR staff indicated that they evaluated residents’ statuson a quarterly basis; another 9 said they conducted a reviewonly if a resident had what they called a significant changein condition. The MDS 3.0 and the Brief Interview for MentalStatus portion of the MDS 3.0 were the most commonmethods used to assess residents’ status.

Perhaps more problematic, the interviewees revealedthat they were not using or sharing the informationgathered during the screening and assessment process.Twelve of the PASRR staff reported that level I informationwas filed only in residents’ medical charts, and only 7mentioned distributing this information to other nursingfacility staff. Ten respondents stated that the screeninginformation was not useful at all. When asked how theirfacilities use the level II assessment, only 12 respondentsreported using the information to develop a plan of careinvolving the provision of specialized services to olderpatients. This pervasive lack of information sharing withresidents and with the nursing facility treatment teamseems at odds with the NHRA requirement that PASRRassessments be coordinated to the maximum extentpracticable (Omnibus Budget Reconciliation Act of 1987).

Current Condition of Nursing Facility ResidentsThe IOM (2012) reported that 57 percent of nursing

facility residents over age 65 (675,622 people) had at leastone psychiatric condition. Depression was most common,followed by anxiety, schizophrenia, and bipolar disorders.Although PASRR does not explicitly apply to the estimated60 percent of nursing facility residents with a primarydiagnosis of dementia or neurocognitive impairment(because they were not defined as psychiatric conditions in the NHRA), the IOM (2012) nevertheless reported that 28 percent of nursing facility residents had identifiedbehavioral problems, many of which could be tied to


dementia and decreased cognitive functioning and many ofwhich could be treated effectively with specialized services.Moreover, these prevalence rates have steadily increasedover the last 10 years and, compared with those who areadmitted without a psychiatric condition, individuals withpsychiatric conditions now are more likely to becomenursing facility long-stay residents (IOM, 2012). These datastand in contrast to the number of nursing facility residentswho are being identified as having a psychiatric need by thePASRR process.

Knight, Kaskie, Shurgot, and Dave (2006) added that,altogether, less than 6 percent of older adult nursing facilityresidents with a diagnosable psychiatric condition receivedspecialized services from a qualified Medicare provider, andthe provision of specialty care has been curtailed furthersince 1998, when Medicare implemented the nursing homeprospective payment system. In short, despite the fact thatthe population of nursing facility residents with psychiatricconditions has grown and will continue to increase in the next decade, a sufficient amount of evidence shows

that PASRR has not met its objective of offeringnonpharmacological specialized services as an alternative to medication therapy.

At this point, as we look to discuss what lies ahead forPASRR, we are disarmed by the notion that we have yet toconsider one of the other most common places forproviding long-term residential care to older adults withpsychiatric conditions: assisted living facilities. The IOM(2012) reported a total of more than 30,000 assisted livingfacilities in the United States, with a resident population ofnearly 650,000 over the age of 65. More pertinent here, theIOM indicated that up to 30 percent of these residents haddepression, anxiety, or some other serious psychiatricdisorder. In addition, nearly 60 percent of assisted livingresidents have dementia, and many of these exhibittreatable affective and behavioral symptoms. No federal orstate laws require assisted living facilities to identify, treat, orrefer residents with psychiatric conditions. In other words,PASRR stops with nursing facilities.

Discussion To be sure, PASRR has corresponded with a number of

positive impacts on the provision of care to older nursingfacility residents with psychiatric conditions. PASRR hasincreased awareness about psychiatric conditions amongolder adults and has slowed the admission of people withpsychiatric needs into nursing facilities that cannot care forthese needs. Although not addressed in this report, thePASRR process also has improved the identification andevaluation of people under 65 with psychiatric conditionsand developmental disabilities. Indeed, the PASRR processseems to have reduced the number of facilities that serve asa warehouse for older individuals with psychiatricconditions (Linkins et al., 2006b; Timmel, 2005).

Moreover, the Centers for Medicare & Medicaid Services(CMS) has diligently pursued corrective measures inresponse to investigative reports and research studies(PASRR Technical Assistance Center, 2010; Timmel, 2005).Since 2007, CMS has increased efforts to recoup paymentsfrom noncompliant nursing facilities; CMS (2011) has also

created quality indicators focusing onbehavioral health and psychiatric issues thathave been incorporated into the MDS.Community placement is being taken moreseriously in light of the Supreme Court’s 1999Olmstead decision; consequently, the nationalPASRR Technical Assistance Center wascreated, along with a professionalorganization of PASRR professionals. LikeIowa, states that previously made little effortare now engaged in administering the PASRRprocess, and clinical researchers areincreasingly working to create evidence-based, nonspecialized service approachestailored to residential environments (IOM,

2012; Molinari et al., 2013).Nevertheless, given the continued (over)reliance

on medications, the failure to expand non-psychopharmacological treatment approaches, and the increasing amount of long-term residency among older adults with psychiatric conditions, nursing facilitieshave started to look more and more like the residentialpsychiatric hospitals of the past—except they are arguablyproviding less in the way of psychiatric care. Furthermore,with the imminent entry of more than 75 million babyboomers into a national long-term care system that doeslittle in the way of protecting (or discharging) individualswith psychiatric conditions who reside in nursing facilities, it seems about time for the 25-year-old PASRR program togrow up.

The list of what could be done to improve PASRR is long and well rehearsed (Bazelon Center, 2012). Exemptionsfrom screening hospital transfers need to be examined more closely. Exceptions in providing care for affective


Prescription medication therapyhas remained the de facto form ofspecialized service delivery fornursing facility residents withmental illness.



and behavioral health problems amongpeople with neurocognitive impairment shouldbe removed. Nursing facilities should berequired to train staff in a minimum set ofcompetencies relating to mental health issuesand PASRR, as well as when PASRR rescreeningshould occur. Furthermore, the provision ofpharmacological services must be monitoredmore closely. The CMS and individual stateauthorities must define, develop, and finance amenu of nonpharmacological services staffedwith an appropriately trained workforce. Inaddition, state authorities should start using PASRR data toguide oversight functions designed to improve the PASRRprocess, and greater emphasis must be placed on returningindividuals to the least restrictive setting available.

Following on this last recommendation, in accordancewith the Olmstead decision, one of the most substantivechanges to the MDS 3.0 involved the addition of a question to identify residents desiring to return home or betransferred to a less restrictive setting. However, few effortsseem to be taken in this direction. One of the PASRR staff weinterviewed said that she had never seen anyone dischargedfrom the long-term care side of her facility, and we foundlittle indication that PASRR staff speak with residents abouttreatment goals and then take action to move residentsback into integrated community-based forms of care. Giventhe growing number of decisions in which courts havefound violations of the integration mandate of theAmericans With Disabilities Act, especially in the context ofnursing facilities (Rolland v. Patrick, 2013; Joseph S. v. Hogan,2008), perhaps this is an opportunity for courts to advancethe maturation of the PASRR program in a way the executiveand legislative branches have not.

Why Isn’t PASRR Maturing? Arguably, there are two reasons why PASRR will never

grow up. On one hand, clinical and health servicesresearchers have yet to establish the value of widespreadimplementation of nonspecialized services relative to otherapproaches. Does individual counseling provided by alicensed therapist correspond with significantly betteroutcomes than what occurs when a person is medicated, isoccasionally talked to by nonlicensed attendants, and is aperiodic participant in social and recreational activities (i.e.,less intensive therapeutic services)? Do specializedtreatments decrease emergency room visits or inpatienthospital admissions or reduce other types of health servicecosts? Are residents who receive specialized services morelikely to return to the community? Even if these questionswere answered affirmatively through a series of researchstudies focusing on comparative effectiveness or patient-centered outcomes, the implementation of evidence-basedservices will remain challenged by the well-documented

lack of dedicated financing and workforce supply for theprovision of specialized services within nursing facilities(IOM, 2012).

On the other hand, efforts to improve the process will necessitate increased oversight from state authoritiesthat are charged with upholding and enforcing the federalPASRR standards. However, we remain circumspect,because previous calls for such increased oversight have largely fallen on deaf ears in state legislatures and in governors’ offices. Boemhke (2008) reported that a state’s oversight and enforcement depends on a number of variables, among which the level of contributions thatprofessional organizations representing nursing facilitiesprovide to state legislators and governors is quitesignificant. Arguably, as long as nursing facility leadershipdefine any efforts related to PASRR in terms of increasedcost or reduced profit margins, any state that moves to set up and implement an oversight and improvementprocess is more likely to be held in check by campaigncontributions from the nursing-facility industry itself. Moreconsistent and fair oversight processes cannot occur untiloversight for the survey process is moved from the state tothe federal level where, as Boemhke suggested, it is morecostly and less attractive for nursing-facility lobbyists toinfluence members of Congress.

Concluding RemarksTaking care of nursing facility residents with psychiatric

conditions continues to be a daunting task. Theseindividuals often present complex clinical care needs,facilities remain challenged to provide care that is bothprofitable and evidence based, and state authoritiesoften lack the resources and political will needed toadvance improvements. Although several solutions havebeen proposed to address this public-health-policyproblem, there remains a need for researchers toestablish the comparative effectiveness of differenttreatment approaches and place value on individual patientoutcomes relative to the corresponding payments neededto achieve them. Meanwhile, we wonder if any publicauthority can assume the responsibility of parenting a policy program that has not yet reached maturity.

Health services researchers have yetto establish the value of widespreadimplementation of nonspecializedservices relative to other approaches.



Jane Hudson, JD, is executive director of Disability RightsIowa; Lauren Erickson, MPH, graduated from the University ofIowa College of Public Health; Scott Lyon, JD, is a staff attorneyfor Disability Rights Iowa; Jayna Grauerholz, JD, is a staffattorney for Disability Rights Iowa; Jean Herrity is a paralegalfor Disability Rights Iowa.

ReferencesAmericans With Disabilities Act of 1990, 42 U.S.C.A. § 12101et seq. (West 1993).

Ascend Management Innovations. (2012a). 2011–2012 fiscal year activity report (document in possession of the authors).

Ascend Management Innovations. (2012b). December 2012 monthly activity report (document in possession of the authors).

Bazelon Center for Mental Health Law. (2012). Disintegratingsystems: The state of states’ public mental health systems.Washington, DC: Author.

Boemhke, F. J. (2008, January). Subverting administrativeoversight: Campaign contributions and nursing homeinspections. Paper presented at the annual conference ofthe Midwest Political Science Association, Chicago, IL.

Centers for Medicare & Medicaid Services. (2011). Stateoperations manual: Appendix PP—Guidance to surveyorsfor long term care facilities. Retrieved fromhttp://www.cms.gov/site-search/search-results.html?q=state%20operations%20manual

Committee of Nursing Home Regulation, Institute ofMedicine. (1986). Improving the quality of care in nursinghomes. Washington, DC: National Academy Press. Availableat http://www.nap.edu/openbook.php? record_id=646

Community Mental Health Act of 1963, Pub. L. No. 88-164,77 STAT 282 (1963).

Department of Health and Human Services, Office ofInspector General. (2011, May). Medicare atypicalantipsychotic drug claims for elderly nursing home residents.Retrieved from http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf

Institute of Medicine. (1986, January). Improving the qualityof care in nursing homes. Washington, DC: NationalAcademies Press. Retrieved from http://www.iom.edu/Reports/1986/Improving-the-Quality-of-Care-in-Nursing-Homes.aspx

Institute of Medicine. (2012). The mental health andsubstance use workforce for older adults: In whose hands?Washington, DC: National Academies Press. Retrievedfrom http://www.nap.edu/catalog.php?record_id=13400

Joseph S. v. Hogan, 561 F. Supp.2d 280 (E.D. N.Y. 2008).Kahn, R. L. (1975). The mental health system and the future

aged. The Gerontologist, 15, 24–31.Kentucky State Mental Health/Mental Retardation Services.

(2004). Kentucky PASRR manual. Frankfort, KY: Author.

Knight, B. G., Kaskie, B., Shurgot, G. R., & Dave, J. (2006).Improving the mental health of older adults. In J. E. Birren& K. W. Schaie (Eds.), The handbook of the psychology ofaging (6th ed., pp. 407–424). San Diego: Academic Press.

Li, Y. (2010). Provision of mental health services in U.S.nursing homes, 1995–2004. Psychiatric Services, 61, 349–355. Retrieved from http://ps.psychiatryonline.org/article.aspx?articleid=101303

Linkins, K., Lucca, A., Housman, M., & Smith, S. (2006a, January).PASRR screenings for mental illness in nursing facility applicantsand residents (DHHS Publication No. SMA 05-4039). Rockville,MD: Center for Mental Health Services, Substance Abuse andMental Health Services Administration.

Linkins, K., Lucca, A., Housman, M., & Smith, S. (2006b). Use ofPASRR programs to assess serious mental illness and serviceaccess in nursing homes. Psychiatric Services, 57, 325–332.

Molinari, V., Chiriboga, D., Branch, L., Cho, S., Turner, K., Guo,J., & Hyer, K. (2010). Provision of psychopharmacologicalservices in nursing homes. Journals of Gerontology:Psychological Sciences, 65B, 57–60.

Molinari, V., Chiriboga, D., Branch, L. G., Greene, J., Schonfeld.L., Vongxaiburana, E., & Hyer, K. (2013). Effect of mentalhealth assessment on prescription of psychoactivemedication among new nursing home residents. ClinicalGerontologist, 36, 33–45.

Molinari, V., Chiriboga, D., Branch, L., Schinka, J., Schonfeld,L., Kos, L., . . . & Hyer, K. (2011). Reasons for psychiatricmedication prescription for new nursing home residents.Aging & Mental Health, 15, 904–912.

North Carolina Department of Health & Human Services,Division of Medical Assistance. (2005). North Carolinapreadmission screening: Annual resident reviewrequirements. Retrieved from http://www.ncmust.com/doclib/PASARRProviderManualwithForms.pdf

Nursing Home Reform Act (OBRA ’87), Pub. L. No. 111-148,requirements for nursing facilities, codified at 42 U.S.C.1396r (1987).

Olmstead v. L.C., 527 U.S. 581, 587 (1999).Omnibus Budget Reconciliation Act of 1987, Pub. L. No. 100-

203, 101 Stat. 1330 (1987). Overprescribed: The human and taxpayers’ costs of

antipsychotics in nursing homes: Hearing before the SpecialCommittee on Aging, United States Senate, 112th Cong. 1(2011). Retrieved from http://www.aging.senate.gov/publications/11302011.pdf

PASRR Technical Assistance Center. (2010). Introduction toPASRR. Retrieved from http://www.pasrrassist.org/resources/introduction-pasrr

Pre-Admission Screening and Annual Resident Review, Pub. L.No. 100-203, Title IV, Subtitle C, Part 2, § 4211 (a)(3) (1987).

Rolland v. Patrick, 2013 WL 2322761 (D. Mass. 2013).Timmel, D. (2005). Preadmission screening and resident

review [PowerPoint slides]. Retrieved fromhttp://www.public-health.uiowa.edu/icmha/meetings/1018-2109/documents/TimmelPASRR_OverviewDiagrms.pdf


From the Editor • Continued from page 2

form of specialized treatment, and relatively few efforts have been made to provide nonpharmacological services.An estimated 85 percent of newly admitted nursing homeresidents, most of these with no diagnosed condition, areplaced on some kind of psychoactive medication within 3months of admission. Remarkably, an investigation by theDepartment of Health and Human Services InspectorGeneral found that nearly 90 percent of all atypicalantipsychotic drug prescriptions violated one or morefederal laws. The authors recommend closer monitoring ofdrug usage and development of a more robust workforcefor nonpharmacological interventions. Yet, the overall toneof this analysis is markedly pessimistic; the authors note thatthey have not even touched on assisted living facilities,where less regulation and an increasingly frail populationraise numerous concerns. As for nursing facilities, theauthors view them as coming to resemble the residentialpsychiatric hospitals of yore—except that they are notproviding much in the way of psychiatric care.

Sally Rodriguez focuses on the presence and care ofMedicare enrollees with severe mental illness. Because these individuals use more care than others, the fragmentedsystem of addressing primary, acute, chronic, and behavioralhealth care needs to be better integrated in order to get ahandle on cost escalation and suboptimal patient care in the Medicare program. The author holds out modest hopethat the states acting as laboratories—and several haveundertaken service-system delivery innovations—mightprovide a path forward. However, the historically separateoperation of mental and physical health systems representsa longstanding barrier.

An ongoing issue in the geriatric mental health field has been a shortage of trained professionals,paraprofessionals, and direct care workers. As ChristineBishop points out in her article, numerousrecommendations for remedying this situation have beenforthcoming in recent years, most of which have missed the mark. Bishop focuses on the 2012 report of the Instituteof Medicine Committee on Mental Health Workforce forGeriatric Populations, the latest attempt to address boththe shortage in numbers and the adequacy of thoseindividuals’ preparation for practice. Arguing that the U.S. political and health care system will never be able toproduce an adequate number of health care personneldirected to geriatric mental health care, Bishop notes thecommittee’s recommendation that policymakers take abroad view of workforce capacity. In particular, she stressesthat increasing capacity of all health personnel workingwith older adults to identify, refer, and, in some cases, treatthose older adults presenting with mental health andsubstance abuse issues; increasing the capacity of providersworking with the broader population to better addressolder adult issues; and developing innovative systems ofcare would all be beneficial. Specialty care is all to the good,

but a more realistic approach is to enlist the capacity of allhealth care workers toward better addressing the needs ofthis especially vulnerable population.

Ryan Carnahan and colleagues explore the challengesassociated with the use of antipsychotic drugs in individualswith dementia. Although these drugs are appropriate insome situations (“treating unmanageable aggression,psychosis, or other symptoms that cause severe distress orthreaten the safety of either the person with dementia orothers”), usage is back nearly to pre-OBRA levels and, theauthors argue, no good alternatives are currently available.The authors call for better (nonpharmacological)environmental management strategies and new researchemploying high-quality designs to move the field forward.Understanding that good data on the efficacy ofnonpharmacological interventions are not available, theynonetheless cite Livingston and colleagues to the effect that“lack of evidence of efficacy does not mean lack of efficacy.”

A final contribution addresses the underreported andmuch-misunderstood phenomenon of suicide among olderadults, in particular suicide associated with firearms. As aquestion of public health, the suicide rate is higher amongthe older population than the younger, an estimated 90percent of older adults who commit suicide havepsychological disorders, and serious physical illness plays a role in some 70 percent of elder suicides. Having brieflyreviewed those sad realities, Mark Kaplan and WilliamCoryell turn to the alarming role of guns in suicide cases.Noting that the decision to commit suicide results from acomplex interaction of individual and contextual factors, the authors cite another study by Kaplan demonstratingthat one of the most salient predictors of suicidal behavior isfirearm availability, a finding indirectly corroborated by self-inflicted gunshot deaths occurring disproportionatelyamong older, married White men from the Deep South. The authors go on to cite studies indicating that gun controllaws do reduce the overall suicide rate, with one analystsuggesting that such laws might reduce the rate by asmuch as 25 percent.

Finally, Kaplan and Coryell note that a remarkable 70 percent of older suicides had seen their primary carephysician within a month of their suicide. Whether aconsequence of older adults failing to report feeling down or depressed, or of physicians tending to spend less timewith older than younger patients, the authors suggest thatgreater attention on the part of primary care physicians tomental health and potential suicidal behavior seems to be inorder. However, as the authors somewhat ruefully note, thedebate here dramatically shifts ground, with gun controlopponents arguing that health care providers questioningpatients about gun ownership and usage would infringe onpatients’ Second Amendment rights—a sobering conclusionto the final article in this issue of PP&AR on mental health,where the need for sobering is very much in order.

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