The underside of the silver tsunami--older adults and mental health care.

n engl j med 368;6 nejm.org february 7, 2013 493 10.1 million to 14.4 million by 2030.1 Yet the American Geriatrics Society estimates that there are fewer than 1800 geriatric psychiatrists in the United States today and that by 2030 there will be only about 1650 — less than 1 per 6000 older adults with mental health and substance-use disorders. The IOM’s 2012 workforce report on this topic, aptly subtitled In Whose Hands?, confirms that we will never be able to train enough specialists in geriatric medicine and geriatric psychiatry to care for this rapidly growing and highly vulnerable population. Indeed, more than half the fellowship positions in geriatric medicine or geriatric psychiatry go unfilled each year (see graph), and according to the American Psychological Association, only 4.2% of psychologists focus on geriatrics in clinical practice. Older adults with mental health disorders have greater disability than those with physical illness alone, as well as poorer health outcomes and higher rates of hospitalization and emergency department visits, resulting in perperson costs that are 47% to more than 200% higher.1,2 Yet mental health services account for only 1% of Medicare expenditures.1 Formulating and implementing policies to build the geriatric mental health workforce to address these needs has been notoriously difficult, especially since different federal agencies hold responsibility for mental health services and aging services. Fortunately, the IOM report resists declaring yet another “crisis” requiring the training of more geriatric specialty physicians — an alarm and recommendation that has been repeated in vain for more than 90 years.3 Instead, the unprecedented aging of the population requires an unprecedented shift in the delivery paradigm for geriatric mental health care. The new Medicare Annual Wellness Visit highlights for primary care physicians this challenge of meeting the health care needs of older adults: it requires screening for depression as well as the detection of cognitive impairment, thus adding newly identified disorders but without additional resources, trained personnel, or additional reimbursed time to provide follow-up services. The IOM report begins to address the shortfall of geriatric mental health The Underside of the Silver Tsunami — Older Adults and Mental Health Care