October 3, 1973
Page 32698
NEEDED: A NATIONAL MENTAL HEALTH POLICY FOR THE ELDERLY
Mr. MUSKIE. Mr. President, the Senate Special Committee on Aging, on which I serve as chairman of the Subcommittee on Health of the Elderly, has long been concerned about mental health problems of older Americans.
Part of our concern arises from the fact that geriatric patients now occupy one of every five beds in our Nation's mental hospitals. In addition, perhaps 15 to 25 percent of elderly persons living in their own homes have some degree of mental impairment.
Furthermore, we have received reports of "warehousing" of the elderly in institutions of some States while from other States we hear of "dumping" of the elderly from institutions into the community without any real regard for their well-being.
At the heart of such problems are negative attitudes toward the elderly. As an official of the National Association of State Mental Health Program Directors recently stated:
The mental and emotional well-being of the aged has been particularly neglected probably because "senility" is so often believed to be an inevitable and irreversible consequence of aging.
Another consequence of such attitudes is that older persons are drastically under-represented in community mental health programs.
The Senate Committee on Aging, in November 1971, issued a report summing up problems related to mental health of the elderly. Since that time I have introduced legislation calling for a bill to establish a Commission on Mental Health and Illnesses of the Elderly. My arguments for that bill are stated in the May 9, 1973, issue of the CONGRESSIONAL RECORD.
A Commission, however, much as it may be needed, is only one element in a truly national effort needed in this area.
For that reason I was much impressed by a farsighted, challenging address made by Bertram S. Brown, M.D., Director of the National Institute of Mental Health, at the Governor's Conference on Aging in Nashville, Tenn., on September 26.
Dr. Brown provided an admirable summary of the scene today, saying:
We see resources that are scattered and often used inappropriately. Coordination at the service or consumer level remains a goal rather than a reality.
Dr. Brown, recognizing the difficulties that could block the way for constructive action, nevertheless asks for a long-needed, "a national mental health strategy for the elderly," and he provides 10 program goals.
Mr. President, Dr. Brown has long been recognized as a resourceful and highly informed advocate for the wellbeing of all Americans. His statement on older Americans is a significant and timely message.
I ask unanimous consent that his address be printed in the RECORD.
There being no objection, the address was ordered to be printed in the RECORD, as follows:
WHERE Do WE GO FROM HERE?
(By Bertram S. Brown, M.D.)
This has been a very stimulating session. To present summary reports on two days of workshop discussions is no small task but really quite a challenge in linguistic logistics. The Group Reporters have succeeded commendably in conveying, I am sure, the representative interests, impressions, ideas, and concerns of all the discussants.
My task now seems at least equally challenging. To assimilate and comment on the information- laden Group Reports is not only a logistic problem but a political one as well. Transportation, mental health, health and nutrition are indeed inseparable issues in any comprehensive program designed to meet the consumer needs of the Nation's and, specifically, Tennessee's elderly. While I acknowledge the significance of the entire spectrum of topics you have covered throughout this Conference, my politics now will be local, and as Director of the National Institute of Mental Health I will focus on concerns most pertinent to that aspect of the Conference.
The issues and opportunities so well spelled out in the discussion reports are high profile reminders of the urgency and wisdom of a national mental health policy for the elderly.
The need is pressing: psychopathology in general and depression in particular rise sharply with age. Suicide reaches a desolate peak among white, elderly males. Loneliness, anxiety, and boredom too often characterize the lives of the old. Many feel isolated, useless, and unwanted.
These are mental health concerns. Too often, the loss of and changes in work and social status cause older persons to lose confidence in themselves, and this is a mental health concern. When through the death of or separation from contemporaries the older person withdraws socially, it is a mental health concern. The contingencies of diminished income and financial dependency become mental health concerns.
In short, we see a vulnerability induced in the old by society's failure to meet their elementary needs for socialization, good health care, special housing arrangements, or adequate income – this becomes a mental health concern, and through our effort, a concern that can be remedied.
In recent years, increased national exposure has been given to this problem. The President's Task Force on the Aging, in 1970, expressed concern regarding "the use of State mental hospitals as custodial facilities for large numbers of chronically ill or disabled older persons who are not in need of active psychiatric care because alternative living arrangements with psychiatric consultation or support do not exist .
At that time, the Senate Special Committee on Aging, in anticipation of the White House Conference on Aging in 1971, issued a report entitled: Mental Health Care and the Elderly: Shortcomings in Public Policy, which referred to the "widespread confusions and contradictions in public health policy on mental health of the elderly (which) are causing heavy economic, social and psychological costs among older Americans and their offspring." These costs are paid by some elderly misplaced in institutions when they could – with appropriate services – return to the community. Others pay that cost by remaining in their own homes, "in confusion or despair, denied access to services which help others but not them."
Outside the Federal sphere, the Group for the Advancement of Psychiatry in its publication "Toward a Public Policy on Mental Health Care of the Elderly" stated that "the elderly suffer disproportionately from our non-system of non-care, characterized by insufficiently financing for both health and sickness and by fragmented delivery of services."
In 1971, the Special Concerns Session on Mental Health Care Strategies and Aging of the White House Conference recommended the establishment of a Presidential Commission on Mental Illness and the Elderly. This Session further proposed that there be recognition and support of the individual's right to care and treatment within the full range of mental health services, that adequately staffed and programmed comprehensive local mental health services be developed for the elderly, and that greater efforts be made to develop options to institutional care.
On a third front, a critical front in the drive for greater equity in resource allocation, are the organized senior citizen groups whose membership has multiplied tenfold during the past decade.
These individuals recognize that a most crippling loss of old age has been that of choice. Today, the older consumer is no longer satisfied to be at the mercy of the providers of service. He expects to bargain with dignity and freedom in the marketplace as does any other consumer. But he can do this only when services are available so that options are assured.
One of our primary responsibilities, from the Federal to the community level, is to look critically at the services and service options currently available to the elderly.
When we do, we see an accumulation of untreated illness. We see resources that are scattered and often used inappropriately. Coordination at the service or consumer level remains a goal rather than a reality.
Citing nationwide statistics, congregate care facilities provide 85 percent of the mental health care received by the elderly. One million older persons live in these facilities – in State mental hospitals and nursing homes – throughout the country, and often through no choice of their own. We estimate that 300,000 to 500,000 of these million persons are not primarily in need of such services and could better be provided for in more appropriate facilities and through alternate service systems.
In part, a scarcity of more suitable community resources, including mental health services, limits the range of choice. Also, program restrictions frequently limit the potential of family and community contributions. Strengthening these programs lessens the pressure on more expensive institutional care, permits facilities to better serve those who most need their services, and helps correct an imbalance as damaging to society as to the elderly.
A hopeful sign is the growth of community based mental health facilities. In 1955, 77 percent of all psychiatric patient care episodes were provided inpatient services and 23 percent treated in outpatient facilities. By 1971 only 42 percent of all psychiatric patient care episodes were provided inpatient services, and 58 percent outpatient.
In 1973, this trend is unmistakable. The reversal parallels the phenomenal reduction in State mental hospital population. To impede it will inevitably limit the range of quality choices to institutional care, with consequent impact on the mental health of the older person served.
Tempering our program aspirations with the hard, cold logic of events we must recognize the emerging framework for workable strategies as we develop responses to mental health needs of the elderly. That framework includes: budget austerity, national health insurance, augmentation of third party payments, revenue sharing services, integration of services, decentralization, institutional reform, and cost-accounting.
Realistic program support will require a blend of strategies based on principles accepted by taxpayers, consumers, providers, and professionals.
A delicate recipe, this blend calls for working coalitions and incentives that will make it possible. Just as we cannot achieve a socially desired goal such as reducing a hospital population at the expense of its staff, neither should we allow the depopulation of hospitals to the detriment of patients and their families. Nor should one agency be obligated to operate in default of another's responsibility.
A working collaboration, or mutual aid in behalf of the elderly, is essential in responding to the wholeness of their needs.
In addition to working coalitions differentially responsive to older consumers and their families, effective strategy relies on program accountability. Accountability is linked to program survival. Necessarily, that accountability will be measured by its impact on people.
Looking to our own house first, the NIMH has intensified activities to implement its focus on aging as an Institute priority within existing resources:
Extramural research grants affecting the elderly have been increased;
Training activities have been augmented, particularly affecting nursing home manpower;
Collaborative activity with other groups and agencies such as HEW's Administration on Aging and the Department of Housing and Urban Development (HUD) was increased;
A series of interrelated planning and evaluation activities were initiated to provide a firm data base for expanded programs for the elderly;
In the NIMH State Program Development office, where aging is a high priority, several publications were issued that are enjoying wide acceptance..
Still, a significant expansion of NIMH programs requires additional resources.
Research during the past decade has provided added impetus to our efforts. Recent findings suggest that functional mental impairment in older persons is as responsive to treatment as with younger persons. Such studies indicate that apathy, isolation and regressed behavior can be reduced by adequate assessment of the improvement potential and the specific modes of intervention.
As a psychiatrist and science administrator, I would be uneasy if geriatrics research promised magic formulas or elixirs. I would be equally uneasy if NIMH financial and human investments in research on problems of the aged did not promise significant improvements in treatment, service systems, and manpower qualified to meet the psychosocial needs of older Americans.
Armed with such research findings and supported by a growing community of experienced professionals in the field; provided with political mandates at the Federal, State, and local levels of government, and spurred on by both the needs and assistance of citizen groups across the country, where do we go from here? What must be done to insure the continued day-to-day success in the field of this conference and others like it?
Communication of new information represents one challenge. There is mounting evidence of the rehabilitation potential of the elderly by practitioners in the field. Yet somehow this has not been translated into practice.
Considerable research has dealt with negative attitudes that permeate the area of geriatrics. It was found that both administrative and treatment staff inappropriately fear that the elderly are unresponsive and unrehabilitatable. Popular misconceptions about treatability often delay seeking help until a crisis develops.
As health and welfare professionals, we must appreciate that treatment goals for the elderly often serve different needs than for the young. They do not always imply recovery. Slowing the progress of the disease may be called for, whereas a return to productivity might not be practical.
Any effort to develop a national mental health strategy for the elderly must need criteria set by diverse interest groups. It must be goal-centered, visible, workable, and provide good returns for the dollars expended. While it would require a budget and problems inherent in equitable allocation of resources, it would emphasize program results which could be supported by all. The strategy must be responsive to the needs of our citizens and not just geared to the convenience of our desks.
With Federal agencies serving as a national spearhead working in collaboration with state and local departments and citizen consumer groups, a national policy might reasonably move toward achievement of the following program goals:
(1) Reduce inappropriate institutional care of the elderly by at least 10 percent per year through phasing out the use of congregate, custodial care facilities and phasing in small, individualized social, protective, and health care settings of quality service in the community.
(2) Support community projects having mental health relevance and make available to the elderly in their own neighborhoods and with their participation a broad range of community services.
(3) Foster collaboration in service delivery at the consumer level through political, financial, and personal support of coalition planning.
(4) Work toward elimination of exclusion and discrimination against the mentally impaired aged in existing and proposed financing mechanisms including Medicare, Medicaid, health maintenance organizations, the categorical aids, revenue sharing, and the proposed third party payment plans.
(5) Contribute to the establishment and achievement of humane standards of care for older patients through support of nursing home training and ombudsman programs.
(6) Work toward recognition and support of the right to care and treatment for the aged mentally impaired.
(7) Study the barriers to quality care and the obstacles to compliance with standards for dissemination and use in a nationwide program development.
(8) Encourage initiation of additional geriatric programs through mental health centers or other community mental health related facilities.
(9) Expand the existing number of training places for mental health manpower serving the elderly.
(10) Augment existing support for a broad range of basic and applied research to increase knowledge of the cause, prevention and treatment of mental disorders in later life and to provide a better knowledge base for policy decisions affecting the mental health of the elderly.
While it seems most efficient to retain the primary research planning and support function at a coordinated Federal level, in local governance we should be attuned to the profitable opportunities for Federal-private collaboration in research support.
For our own part in furtherance of these objectives, the National Institute of Mental Health can focus its resources and leadership to keep program objectives clearly visible, hold program units accountable for program targets, vigorously assess the impact of what we do, encourage collaborative efforts, support regions and States financially and through technical assistance, speed the dissemination of information about successful projects, help maintain standards, and prompt constituent groups involvement in program development.
These program goals are, I believe, a balanced and, more importantly, a feasible blend of group interests. They seem to represent what most people want.
The citizen impact of such goals are measurable. They are dignifying and humane. Means for their achievement have been demonstrated. Payoff is high, Supporters can be found across the country. And leadership is able and willing.
With your assistance, backing, and good will, perhaps we can begin.