The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?
The aging of America holds profound consequences for the nation. The
number of adults age 65 and older is projected to soar to 72.1 million by 2030—
up from 40.3 million in 2010. During the same period, the ethnic, racial, and
cultural makeup of the older adult population will become more diverse than
ever, and the health care demands and costs resulting from these demographic
shifts are expected to be unprecedented.
In 2008, the Institute of Medicine (IOM) issued Retooling for an Aging
America: Building the Health Care Workforce, which highlighted the urgency
of expanding and strengthening the geriatric health care workforce. Because
of similar concerns about older adults’ mental health and substance use (MH/
SU) conditions, the Department of Health and Human Services (HHS), as
directed by Congress, asked the IOM to undertake a complementary study
on the geriatric MH/SU workforce. An IOM expert committee assessed the
needs of this population and the workforce that serves it and presents its findings
and recommendations in The Mental Health and Substance Use Workforce
for Older Adults: In Whose Hands? In this report, “substance use” refers to the
abuse or misuse of, or dependence on alcohol and drugs—illicit or legal.
A Vulnerable, Underserved Population
The MH/SU needs of older adults are complex, typically occur with other
health problems, and are often inadequately met by today’s health care system.
At least 5.6 million to 8 million—nearly one in five—older adults in America
have one or more MH/SU conditions, which present unique challenges for
their care. Depressive disorders and dementia-related behavioral and psychiatric symptoms are the most prevalent, but substance
use is a significant problem as well.
Age alters the way people metabolize alcohol
and drugs. Commonly used medications
may worsen physical or mental health problems
and increase an older person’s risk for dangerous
overdose. Losses that occur frequently in old
age, such as the death of a spouse, may trigger or
worsen depression and lead to severe, debilitating
symptoms. Differentiating between major depression
and grief in a person with significant loss is
often difficult. Cognitive, functional, and sensory
impairments also may complicate detection and
diagnosis of MH/SU conditions.
The geriatric MH/SU workforce includes
a wide range of workers who provide diagnosis,
treatment, and care—ranging from personnel
with minimal education to specialty professionals
with the most advanced psychiatric and neurological
training. Across the workforce, there is
little, if any, training in geriatric MH/SU. MH/SU
specialists are not trained in geriatrics, and geriatric
specialists are not trained in MH/SU. Primary
care and other essential providers are not trained
in either area.
Overall, the number of individuals working
in or entering fields related to geriatric MH/SU
is disconcertingly small. Geriatric MH/SU specialists who are the most highly trained to handle
complex MH/SU cases, are in very short supply.
Relatively few opportunities exist for health care
professionals to specialize in geriatric MH/SU.
No financial incentives encourage geriatric MH/
SU providers to enter and stay in the field, and
there is little support or mentorship for people
who pursue specialization.
Two decades of research show that effective
delivery of MH/SU services—particularly for
depression and substance use—to older adults
requires these essential ingredients:
- Systematic outreach and diagnosis
- Patient and family education and self-management
- Provider accountability for outcomes
- Close follow-up and monitoring to prevent
These elements are best obtained when care
is patient-centered, in a location easily accessed
by patients (such as in primary care, senior centers,
or individuals’ homes), and coordinated by
trained personnel with access to specialty consultation.
Care managers are critical to effective care.