A significant number of adults at any age struggle with mental illness, and health care providers have a number of options for treating a diagnosed mental disorder. However, in a number of cases the treatment of mental disorders in older adults has been observed to differ from the care received by younger adults. A recent study used a nationally representative sample of physicians practicing in offices or community health centers in order to get a clearer idea of the patterns of how the provision of mental health care differs for older and younger adults in the United States.
The survey of physicians analyzed in this study covers 125,029 physician-patient encounters over the course of four years. The researchers focused on four specific types of physician visits related to mental health treatment: visits resulting in the diagnosis of a mental disorder, visits where a medication for a mental disorder was prescribed, visits to psychiatrists, and visits in which some form of psychotherapy was involved. A single visit could fall into more than one of these categories.
The researchers began by looking at the percentage of mental health care visits to a physician as a proportion of all physician visits for younger and older adults. Visits involving a mental disorder diagnosis were much more common for adults ages 21 to 64 than for those 65 and better. For the younger adults, 9.5 percent of all visits involved a mental disorder diagnosis, while only 4.8 percent of visits for those over 65 resulted in such a diagnosis. However, there was much less difference in the overall percentage of patients receiving medication for a mental health condition over the entire four-year period of this study, with 19 percent of younger adults receiving such prescriptions compared to 18 percent of older adults.
Much more significant differences emerged when looking at psychiatrist visits and visits involving psychotherapy. Of younger adults, 4 percent of physician visits were to a psychiatrist, while only 1% of physician visits for older adults were to a psychiatrist. Similarly, 2.3 percent of younger adults visits to a physician involved psychotherapy, compared to 0.6 percent of older adults. In both cases, there was a fourfold difference between younger and older adults.
However, the researchers also recognized that just looking at total percentages of visits over the four-year period may not provide the most useful picture of mental health care visits for older adults. For example, if an older adult is visiting a physician for an injury or chronic condition, then there may be many more visits required. Or older adults may be visiting physicians for many more medical conditions that need attention. In order to adjust for that, the researchers calculated the annual visit rate, which calculates how many people out of 100 in a particular group visit a physician for a condition per year. Looked at in this way, important differences in prescriptions emerge. For every 100 older adults, researchers calculated that there were 121 visits to a physician that resulted in a prescription for a mental health medication per year, which was more than double the rate of 57 for younger adults. By contrast, the number of visits to a psychiatrist or for psychotherapy per year per 100 adults was lower in older adults than younger adults. Interestingly, the rates of being diagnosed with a psychiatric disorder did not differ between younger and older adults.
Because older adults are likely to have a greater number of overall health problems than younger adults, the researchers also looked more closely at the characteristics of the individuals who took part in each type of mental health care visit. Looking at just the visits with a mental disorder diagnosis, they found that older women were more likely than younger women to have a mental disorder diagnosis, but other demographic differences between individuals receiving a mental disorder diagnosis were not found. In terms of the specific diagnosis, not surprisingly, older adults had a higher proportion of dementia diagnoses. The researchers also found that older adults were much more likely to receive a mental health disorder diagnosis from a physician who was not a psychiatrist. Only 19 percent of the physician visits that resulted in a diagnosis involved psychiatrists for older adults, compared to 40 percent for younger adults. For both younger and older adults, a mental disorder diagnosis was accompanied by a prescription in 75 percent of these visits.
Turning to those visits in which a medication for a mental health condition was prescribed, the only significant demographic difference observed was a lower number of prescriptions for older non-Hispanic black adults, compared to younger non-Hispanic black adults. Again, in this group, there was a difference in the percentage of such visits that involved a psychiatrist. For older adults who were prescribed medication for a mental condition, only 4.4 percent of these prescriptions were given at a psychiatrist visit, compared to 17 percent of younger adults. The prescription of medication was accompanied by a mental disorder diagnosis for 19 percent of older adults, compared to these being prescribed for 37 percent of younger adults. For those who were given a diagnosis at the same time as receiving a prescription, for both older and younger adults the most common diagnoses were depression and anxiety. Half of all prescriptions for both younger and older adults were for anti-anxiety medications. Looking at medication types, for anti-anxiety medications and antidepressants, older adults had nearly double the rate of prescriptions each year than seen in younger adults. However, rates of mood stabilizer and antipsychotic drug prescriptions were very similar between older and younger adults.
Older adults seeing psychiatrists were more likely to be treated for dementia and depression than younger adults, while younger adults were more likely to be treated for bipolar disorder, substance use, or anxiety. Where psychotherapy was involved, primary care providers provided psychotherapy to 20 percent of older adults, but only 10 percent of younger adults received psychotherapy from a primary care provider. For older adults, 54 percent of the psychotherapy visits were for depression, as compared to 45 percent for younger adults.
The authors of this study note that treatment of older adults with mental disorders merits special attention due this population’s common use of multiple prescription drugs as well as the potential for increased sensitivity to drugs that can come with age. In light of the higher rate of prescriptions per capita for older adults, they suggested that this data was “heightening the concern about the potential appropriateness of use.” While there are ways to treat both depression and anxiety without medication or with a combination of therapy and medications, it appears that this is happening much less often with older adults. Further study is needed to determine why this is the case. The authors suggest that one possibility for the lower use of psychiatrists by older adults could be a shortage of psychiatrists who accept Medicare. The authors felt that it was encouraging that primary care providers are providing psychotherapy, but also noted that it was “critical that nonpsychiatric providers receive more training in and support for the management of mental disorders in their clinical practice.”
Maust DT, Kales HC, and Blow FC. Mental health care delivered to younger and older adults by office-based physicians nationally. Journal of the American Geriatrics Society. (2015). DOI: 10.1111/jgs.13494