Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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[NAMI], 2006). Indeed, mental health advocates argue that Medicaid coverage ex-

tends only to low-income older adults with severe and persistent mental illness

and fails to address the large public health issue of more common diagnoses of de-

pression and anxiety (Unützer et al., 2006).

Advocates argue that financial incentives need to be offered by public and pri-

vate insurers to encourage providers to employ evidence-based practices. Fur-

ther, there is concern that “carve-out” programs, which separate mental health

care from mainstream medical services, contribute to fragmented and uncoordi-

nated care (Unützer et al., 2006). In fact, Aetna Insurance Company has termi-

nated a contract with a carve-out company and is initiating a three-prong

approach to depression: training of primary care physicians and office staff to

screen for depression, a care management system, and access to mental health

specialists (Moran, 2006).

FUTURE DIRECTIONS

Future directions in depression care are currently being shaped by three major

forces: the President’s New Freedom Commission on Mental Health, the National

Alliance for the Mentally Ill, and the 2005 White House Conference on Aging.

In 2002, President Bush appointed a committee to conduct a comprehensive

study of the mental health service delivery system and advise him on strategies

to improve care (Hogan, 2006). The President’s New Freedom Commission on

Mental Health (U. S. Department of Health and Human Services, 2004) identified

barriers to care, including those discussed in this chapter: fragmentation of the

service system, out-of-date Medicare policies, stigma due to mental illness and

advanced age, mismatch between services covered and those preferred, and lack

of adequate preventive interventions and programs that aid in early identifica-

tion. The report clearly indicated that state-of-the-art treatments, based on

decades of scientific efforts, are not being transferred into community settings.

One of the goals set by the report is to move outreach, assessment, and early in-

tervention into low-stigma settings, settings where clients are in touch with help-

ing professionals who can identify mental health needs and link them to mental

health providers. Although the report was not directed to older adults with men-

tal disorder, the calls for elimination of disparities in provision of health and

mental health services and for culturally competent and consumer-directed ser-

vices certainly apply.

Following up on the President’s New Freedom Commission’s finding that the

service system was in poor condition, NAMI (2006) conducted a survey and grad-

ing of the mental health care system in each state. The survey determined that the

national mental health service system is failing; with the country getting no bet-

ter than a D on the report card. All but five states received a C or below. The sur-

vey gathered information from staff at the State Mental Health Authority, from

consumers, and from public records about 10 elements: comprehensive services

and support; integrated system; sufficient funding; consumer- and family-driven

systems; safe and respectful treatment environments; accessible information for

consumers and families; access to acute care and long-term care treatment; cul-

tural competence; health promotion and mortality reduction; and mental health

workforce. In the face of the poor performance of the states on these 10 elements,

Depression 297

NAMI made recommendations, including tying funding to performance and out-

comes; investing in evidence-based and emerging best practices; improving data

collection, reporting, and transparency of information; involving consumers and

families in all aspects of the system; and eliminating discrimination. Several

state innovations were recognized (NAMI, 2006), including local municipalities

taking the lead to address mental health needs through tax and bond proposals;

regulations to reduce use of seclusion and restraints; partnerships between men-

tal health agencies and universities to promote implementation of evidence-

based practices; and efforts to ensure appropriate linguistic skills of the mental

health workforce.

The delegates of the 2005 White House Conference voted mental health into the

top 10 concerns for policy development over the next decade (White House Confer-

ence on Aging [WHCOA] Policy Committee, 2006). Resolution number 8 was “to

improve recognition, assessment, and treatment of mental illness and depression

among older Americans.” For almost 2 years before the conference, the WHCOA

Policy Committee collected public input to guide the delegates’ discussion, and

there was much content put forth on mental health. For example, the National

Coalition for Mental Health and Aging stated that its overall objective was to get

WHCOA to address mental health with the same urgency as physical health, as

recommended by the President’s New Freedom Commission Report (National

Coalition for Mental Health and Aging, 2005). The National Coalition’s testimony

to the WHCOA Policy Committee emphasized the expected increase in need and

demand by aging baby boomers and the fact that currently almost two thirds of

older adults with mental disorder do not get needed services. The coalition also

presented a set of resolutions: Assure access to affordable and comprehensive

range of services (outreach, home- and community-based services, prevention, in-

tervention, acute care, long-term care); assure age-appropriate, culturally compe-

tent, and consumer-driven services; amend statutes to guarantee parity in

coverage and reimbursement for mental health, physical health, and substance

abuse; eliminate exclusions based on preexisting conditions; ensure Medicare

clients have access to the full range of medicines; improve and effectively coordi-

nate benefits at all government levels for dual eligibles; and promote, coordinate,

and finance the movement of evidence-based and emerging practices from re-

search to service.

The delegates endorsed the need to focus national attention on mental health

in our aging society. The final report from WHCOA has not yet been given to the

president or the public, so it is not clear what implementation strategies will be

suggested or how much momentum WHCOA will actually create.

There is much similarity in the messages coming from the President’s New Free-

dom Commission, NAMI’s state report, and the 2005 WHCOA. Clearly, progress on

the issues raised in these forums depends on bridging the gap between research

knowledge and practice and policies related to mental health treatment. Practition-

ers have questioned the usefulness and sustainability of current research knowl-

edge. Future directions in research need to increase the ecological validity of

studies so that real-world clients in real-world situations participate in studies

whose findings translate to practice settings. For example, the majority of current

research findings are based on studies that omit patients with comorbidities in

order to control the confounding variables in determining treatment effectiveness.

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Researchers need to use “patients included for their medical comorbidity rather

than excluded because of it” (Schwenk, 2002, p. 162).

Research also needs to focus on the usefulness and sustainability of empiri-

cally supported treatment knowledge to the practice setting. For example, several

collaborative care studies on colocating specialty mental health providers or de-

pression care specialists in non-mental health service settings have demonstrated

effectiveness, but have failed to sustain interventions beyond their grant funding

due to lack of resources to support the collaboration (Lin et al., 1997; Oishi et al.,

2003). Research initiatives must consider the real-world decision factors of re-

source availability in order to have an impact on the actual delivery of depression

treatment to older adults.

Much of the research on mental health in later life has focused on depres-

sion, yet anxiety is as common as, if not more common than, depression, and

other mental disorders threaten the quality of late life. Researchers should ex-

tend the demonstration and evaluation of treatment models to disorders be-

yond depression.

It is clear that effective treatments exist for depression in later life. It is also

clear that older clients do not receive these treatments and that providers fail to

achieve outcomes that would be expected with these evidence-based practices.

Evidence-based guidelines are available, yet efforts to ensure the use of these

guidelines generally have failed (C. Thompson et al., 2000). There is critical need

for research to illuminate strategies that get effective treatments to older adults,

by changing behaviors of older consumers, families, and primary care and spe-

cialty care providers and by changing policies and systems of care that facilitate

the use of evidence-based interventions.

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