In the year 2030, if things keep on the way they are today, there will be enough geriatric psychiatrists to give each needy patient a 30-second visit. Actually, though, that's a little bit better than things are now, because today each needy patient would get only five seconds per visit.
These statistics, presented at a recent day-long symposium on mental health for the aging, underscore by their patent absurdity the unhappy state of mental health care for a burgeoning population 65 years and older.
Dr. Gary Small, psychogeriatrics coordinator at the University of California at Los Angeles School of Medicine, proffered the concept of the 30-second session, and also told participants that the over-65 population that now numbers about 25 million -- or 11 percent of the total population -- will be about 55 million in the year 2030, almost 20 percent of the projected total population.
Small and other speakers at the symposium, held in conjunction with the recent annual conference of the National Council on the Aging, noted that the largest growth will occur in the population over 75 -- a population in which "the prevalence of disabilities and utilization of medical services increases steeply."
According to Dr. Charles A. Shamoian, director of geriatric services at the Cornell Medical Center, 20 to 25 percent of older Americans, between 6 to 9 million, already "require some form of psychiatric intervention."
Shamoian, who moderated the symposium, noted in a paper accompanying the presentations that "suicide is a possibility in all elderly, not just in the depressed patient." Approximately 25 percent of all suicides in this country occur among the 11 percent of the population over 65.
Moreover, noted Shamoian, "suicide attempts in the elderly are predominantly successful."
Mental health, speaker after speaker reminded an audience that seemed not to need reminding, is a stepchild area of healthcare to begin with, and mental health for the elderly is particularly so.
For example, mental health is the only health category in which there is a lifetime Medicare ceiling. Twenty-one years ago it was set at $250, and it has not changed since.
Said Dr. Barry Lebowitz, chief of the mental disorders of the aging branch of the National Institute of Mental Health, "what $250 bought in 1965 is what it is expected to buy in 1986."
"We continue to practice Peter Pan medicine," said Dr. Robert N. Butler, former head of the National Institute on Aging and now chairman of the department of geriatrics of New York's Mount Sinai Medical Center. "That is a medicine addressed to younger people, not to the complications and realities of old age."
Butler, whose department is unique among American medical centers echoed much of the frustration felt by his colleagues and other mental health professionals specializing in the needs of the elderly.
"We have," he said "an essential failure in the American healthcare enterprise."
He made these points:
Alzheimer's disease -- or the preferred title "senile dementia of the Alzheimer type" (SDAT) -- is the fourth leading cause of death among those older than 65 in the United States, affecting almost 2 million at any given time. But research for it and other mental health problems of the aging accounts for only 2 percent of the entire budget of the National Institutes of Health.
Referring to a report of the Institute of Medicine, Butler said, "we continue to see the scandal of neglect in American nursing homes. Still, only 17 percent of doctors in any given year set foot in American nursing homes. Only 64,000 registered nurses are in 20,000 nursing homes, and very few social workers and hardly any mental health workers, despite the fact that nursing homes are in many respects quality mental institutions. There are now some 1.3 million people in nursing homes, almost double the number in general hospitals on any given day."
"We lack teaching skills about the aging in general and mental health in particular . . . We still do not teach clinical pharmacology so that physicians are aware of the profound complicating effects of powerful drugs on the elderly, often putting older people at risk and causing confused states."
"We still do not have effective health promotion or disease prevention policy in this country. There is no widespread information on nutrition, very little on sexuality and precious little on thanatology the study of death . In short, the very stuff of life itself is not adequately taught within academic medicine or as a reflection of organized medicine as practiced."
One of the most frustrating aspects of the problem, said Lebowitz, is that "there have been half a hundred studies now which, in a whole range of areas, have shown that if you treat the mental health concomitants of everything from hip fractures to cardiovascular disease to stroke, those people will get out of hospital sooner, go to their own homes, rather than to nursing homes, and participate better in rehabilitation."
He and other speakers cited a now classic study in which 24 elderly patients with fractured hips were given mental health assistance -- in that case from psychiatrists -- and then were followed for six months and compared with 26 patients who received no mental health counseling. Hospital length of stay was reduced by 20 percent in the counseled group, and more than twice as many of them went directly home rather than to nursing homes. It was estimated that $183,000 in medical costs were saved by the counseled group.
Said Lebowitz: "You would think the hospital administrators would be pushing this as hard as they could. After all, they're the ones who have to balance the . . . books, and this saves money.
"We're doing everything we can to grab people by the throats and tell them about it," said Lebowitz. "And you know what? They don't believe it.
"Either they're not hearing it in the right way or they're not hearing it from the right people or they don't want to hear it, but they don't believe it.
"The typical response is: How long does psychotherapy last, anyway? Or they talk about the stigma of mental illness. We don't know what else to do. We've presented these materials in congressional hearings, in direct demonstrations, in scientific journals, in countless corridor conversations.
"Short of renting the Goodyear blimp and flying it over RFK stadium during a Redskins game, I can't think of anything else."
Psychotherapy, said Dr. Gene D. Cohen, director of the NIMH program on aging, is "vastly underrated and underutilized in treating the elderly. There is always the attitude of 'Why bother -- it's too late to change and what difference does it make anyway?' "
"Yet," Cohen told the symposium, "we all know about a 19th-century case that really does answer the question of whether an older person can change.
"Here," said Cohen, "is an individual with severe behavioral and psychological problems -- and we all have viewed this man again and again. He is an individual who has gotten more and more entrenched in difficult behavioral problems until, finally, there is an intervention with a team of three.
"Now," said Cohen, "these three clearly had some mental health supervision, because they came in and dealt with him using some conventional therapeutic approaches -- dream therapy, life-review and other historical events.
"And," Cohen said, obviously warming to his subject, "this brief therapy worked in a single night, and here," he said triumphantly "is the happy ending." And he turned on his last slide. There, indeed, is the "patient," sitting at the Christmas table before a fat roast goose. And, as Cohen promised he would be, he is instantly identifiable as Ebenezer Scrooge.