Older adults are much more likely than younger adults to receive prescriptions for psychotropic medications and are significantly less likely to receive care from a psychiatrist, new research shows.
An analysis of more than 100,000 office-based visits showed that older adults had twice as many visits in which psychotropic medications were prescribed than younger adults. However, they were significantly less likely to receive a mental health diagnosis and to be seen by a psychiatrist.
“Treatment of older adults with mental disorders merits additional specific attention, because they often have more comorbid medical problems, are sensitive to psychotropic medication side effects, have greater potential for poly-pharmacy-related adverse events, and will be the fastest growing segment of the population over the coming decades,” the investigators, led by Donovan T. Maust, MD, Department of Psychiatry, University of Michigan, Ann Arbor, write.
“These specific treatment-related concerns can only be addressed when paired with knowledge regarding where and what manner of treatment currently occurs.”
The article was published online July 3 in the Journal of the American Geriatrics Society.
Psychiatrists Less Likely to Accept Medicare
The study follows a recent analysis of the same data source comparing the care of children and adolescents with that of adults, applying the same type of methodology to the younger adult and older adult populations.
“As a provider, I felt that this was interesting because, from my own clinical experience seeing patients, seeing how medications are, or are not, used, seeing how many or few patients are able to get in to have psychotherapy…it was something important to think about, especially as the population is aging,” Dr Maust told Medscape Medical News.
The team gathered data on 100,661 visits to office-based physicians from the National Ambulatory Medical Care Survey. They categorized visits as those resulting in a mental disorder diagnosis, those at which a psychotropic medication was prescribed, visits to a psychiatrist, and visits at which psychotherapy was provided.
The number of each type of visit was divided by patient age (21-64 years and ≥65 years), and the proportion of all office-based care and the annual visit rate per 100 population was estimated. Clinical and demographic characteristics, including sex, mental illness diagnosis, and the use of psychotropic agents, were also taken into account.
The results indicated that older adults were less likely than younger adults to have visits involving a mental disorder diagnosis (4.8% vs 9.5%; P < .001), to have visits with a psychiatrist (0.9% vs 4.0%; P < .001), and to have visits that included psychotherapy (0.6% vs 2.3%; P < .001).
Although the proportion of visits by older adults that involved prescriptions for psychotropic medications was nonsignificantly smaller than the proportion of visits by younger adults (18.1% vs 19.2%; P = .02), older adults had a substantially higher rate of visits for psychotropic medications than younger adults (121.4 per 100 population vs 56.8 per 100 population).
For both groups, depression and anxiety were the most common diagnoses in visits in which psychotropic medications were prescribed.
Discussing the findings, Dr Maust said there are a number of reasons why older adults are less likely to receive their mental health care from a psychiatrist.
“We know that Medicare is the primary source of insurance for older adults, and we know that psychiatrists as a profession are less likely to accept Medicare as insurance compared to other medical specialties,” he said.
“There are few geriatricians, but there are even fewer geriatric psychiatrists, so even if it wasn’t for the insurance issue, there just aren’t many of them. Generally, older adults oftentimes prefer to have their care in a primary setting, so as a group, they may be a little bit more reluctant to see care actually from a psychiatrist, and prefer to get their care in primary care settings,” he added.
As to the reasons why older adults are more likely than younger individuals to receive prescriptions for mental health medications, Dr Maust emphasized that it is not because they are more likely to have a mental health condition.
“Part of the reason that those numbers look so big for older adults is because there are fewer older adults in the community,” he said.
“So the older adults that are coming to get care are seeking treatment for some reason, whether it’s an actual mental disorder or some type of other distress that they’re in because of a recent change or recent illness.
“It might not necessarily be that they have full-blown major depression disorder or a full-blown anxiety disorder, but the providers are trying to help and so are thinking about some of the newer psych medications, thinking that they are relatively safe,” he added.
Roots of Disparities
For Dr Maust, the roots of the current disparities in mental health care between older and younger adults lie in recent policy changes. He noted that 20 years ago, emphasis was placed on screening for depression, because mental disorders were underrecognized in primary care.
“The models of care that came out of that are mostly something that’s called collaborative care, which essentially helps support primary care providers in taking care of patients,” he said.
“Sometimes it involves starting medication, sometimes it involves just checking in on the patient and seeing how they do, and at some future point, either they are feeling better or they are feeling worse, and at that point starting the medication.”
However, recent changes in payment structures for reimbursing healthcare systems and providers have meant that it has become increasingly difficult to implement collaborative care models.
“I think that those models really are a key to solving the supply side because we know, based on the number of psychiatry residents that go in to geriatric psychiatry fellowships, that there’s no conceivable way that there will ever be enough psychiatrists to care for the ageing population in the US,” said Dr Maust.
“The nice thing about these collaborative care models is that they usually have a consultant psychiatrist who’s helping oversee the care of a whole panel of patients that are in primary care. So you can help far, far more patients than you’d ever be able to see individually in your office,” he added.
The research was supported by a Beeson Career Development Award Program and by AFAR, the John A. Hartford Foundation, and the Atlantic Philanthropies. The authors have disclosed no relevant financial relationships.
J Am Geriatr Soc. Published online July 3, 2015. Abstract
Source: http://www.medscape.com/viewarticle/849342?nlid=86583_2981&src=wnl_edit_dail&uac=199847BT&impID=790602&faf=1#vp_1
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