MH in older adults

CQ Researcher

Aging and Mental Health

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Author: Barbara Mantel

Pub. Date: 2023

Product: CQ Researcher

DOI: https://doi.org/10.4135/cqresrre20230324

Topics: Elderly Health Issues, Health, Genetic Disorders and Medical Genetics, Medical Research and

Advocacy, Mental Health, Pharmaceuticals, General International Relations, International Relations, Internet

and Social Media, Media, Aging Issues, Social Services and Disabilities, People with Mental Disabilities,

Congress Actions, U.S. Congress

Access Date: May 10, 2025

Publisher: CQ Press

City: Thousand Oaks

© 2023 CQ Press All Rights Reserved.

Introduction

By 2034, the number of adults aged 65 and older is expected to outnumber children for the first time in U.S.

history. Older adults face unique risks for mental illness, including the emotional stress from health disorders

more common to older age, the loss of purpose that can accompany retirement and loneliness that can re-

sult from the death of friends and family. Yet their rates of mental illness, though significant, are lower than

younger cohorts, for reasons that are not entirely clear. This trend is holding during the COVID-19 pandem-

ic despite the higher risk to older Americans for severe illness and death from the virus. Still, relatives and

many medical professionals often fail to recognize mental health problems in older people, mistakenly believ-

ing symptoms are a normal part of aging. Mental health professionals who specialize in treating the geriatric

population are rare. Experts say primary care physicians must be better trained in basic geriatric psychiatry

and collaborate with consulting psychiatrists to connect older adults to appropriate care.

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Adults aged 65 and older are projected to outnumber children by 2034. As the share of

Americans who are older increases, understanding this population's mental health needs

becomes more important. Primary care doctors and other medical professionals need better

training to understand mental health in the geriatric population as well as how ageism can

hinder health care.

(Screenshot/Center for Health Care Strategies)

Overview

Neil McLachlan is worried about his 91-year-old father.

Three years ago, John McLachlan was diagnosed with parkinsonism, an umbrella term for brain conditions,

including Parkinson's disease, that result in slowed movements, rigidity and tremors. While he has an occa-

sional stutter in his step, McLachlin does not need a walker, takes medicine that controls his shaking and

shows few signs of cognitive decline.

However, over the past two years, the former corporate chief financial officer has gradually lost interest in

activities and people, says his son, Neil. Now John prefers to sleep all day and only reluctantly engages in

conversation. “We're all grieving the loss of this dynamic person,” Neil says.

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The mental health needs of older Americans are often misunderstood. While this population

does not experience mental illness at higher rates than younger cohorts, medical profes-

sionals often fail to diagnose issues accurately, believing that the symptoms are a normal

part of aging.

(Pexels/Nicola Barts)

Neil and his wife live in the same Florida condominium complex as his parents. Recently, friends and relatives

there have gently suggested that his father might be depressed. “I don't know enough about depression,” he

says and has been “loathe” to bring it up with his sister, Ruth, who coordinates their father's medical care and

hosts their parents from May through October at her Virginia home.

While older adults do not experience mental illness at higher rates than their younger counterparts, they do

face unique risks to their mental health, experts say. These include the emotional stress from health disorders

more common in older age, such as heart disease, dementia and cancer; the loss of purpose that can some-

times accompany retirement; and the loneliness that can result from the death of spouses, friends and family.

In addition, relatives and even medical professionals often fail to recognize mental health problems in older

people, mistakenly believing the symptoms to be a normal part of aging, say experts.

The size of the U.S. older population is steadily increasing, as is its share of the total population. By 2050,

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22 percent of the nation is projected to be aged 65 or over. The year 2030 will be a turning point, when all

Baby Boomers will reach retirement age, according to the U.S. Census Bureau. By 2034, agency researchers

project that older adults will outnumber children for the first time in the nation's history.1

Experts agree that there are not enough mental health professionals, particularly in rural areas, to meet older

patients' needs now and into the future. It is a problem for all age groups, says Lisa de Saxe Zerden, an asso-

ciate professor of social work and research fellow at the University of North Carolina at Chapel Hill's Carolina

Health Workforce Research Center. “It's incredibly alarming when you think about behavioral health needs

across the life course, from infant mental health, to youth, to teens and all the way through geriatrics.”

Resilience Grows with Age

Older Americans as a group are more resilient than younger people when it comes to mental health, for rea-

sons that are not entirely understood, says Dr. Dan Blazer, a professor of psychiatry and behavioral sciences

at Duke University School of Medicine. This pattern has held true during the COVID-19 pandemic, even as

older adults face higher rates of serious disease and death from the virus. For example, the percentage of

adults between the ages of 18 and 64 who regularly experienced feelings of depression in 2021 approached

5 percent, according to a national survey from the Centers for Disease Control and Prevention; the percent-

age for Americans aged 65 and over was 3.6 percent.2

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In another survey conducted by a group of academic researchers from March 2020 through April 2021, older

adults were more concerned about their personal health risk from COVID-19 but less worried about social

isolation than younger people. Older survey respondents reported lower stress and fewer symptoms of de-

pression than younger respondents.3

The study did not ask about methods for coping with their fears, but years of research suggest that older

adults may be better at emotion regulation, says the study's lead author, Eric Fields, a cognitive neuroscien-

tist at Westminster College in New Wilmington, Pa. “Older adults tend to pay more attention to and remember

positive things more than negative, and younger adults show the reverse effect.”

Serious mental health disorders, such as schizophrenia, anxiety disorders, bipolar disorder and major depres-

sion also tend to be less frequent than in earlier life, says Blazer. Still, “it doesn't mean that they don't occur

in older adults, and they can be pretty significant, so we need to be paying attention,” he says.

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It is not clear why the prevalence of serious mental health illness declines with age. It could be that conditions

such as schizophrenia and bipolar disorder somehow burn out in the brain over time, Blazer says. In addition,

triggers for major depression, such as divorce and job loss, tend to be less common in older Americans. Blaz-

er says there is another possible explanation. “The life expectancy of people with mental illnesses is shorter,

and, therefore, many of them don't survive into late life.”

Missing Mental Help

It is more difficult to diagnose conditions like anxiety and depression in older people, says Dr. Dilip Jeste, for-

mer senior associate dean for healthy aging and senior care at the University of California, San Diego, and

the founder of the university’s geriatric psychiatry program. Part of the problem is ageism, Jeste says. “There

can be an expectation that if somebody is depressed or anxious, it is just the normal phenomenon of aging,

whereas if a 35-year-old complains about depression, nobody is going to say that is normal.”

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Blazer says that symptoms of depression in older adults can fool many doctors into thinking the problem is

physical. “Older persons tend to experience more … biological symptoms of depression: sleep problems, ap-

petite problems, weight loss, lack of energy, lethargy and apathy,” Blazer says. “You don't have the severe

crying episodes as much as you do in younger people.”

That is why it is so important for older adults to see psychiatrists or other mental health providers who spe-

cialize in geriatric care, experts say, since they may be more likely to recognize depression as the cause of

these physical symptoms than a primary care physician would be.

At the same time, these specialists are more likely to recognize when mental illness is not the cause of what

appears to be a psychiatric problem and will look for drug interactions, drug toxicity, a physical condition or

infection, says Dr. Helen Lavretsky, president-elect of the American Association of Geriatric Psychiatry, a pro-

fessional medical society. “For example, when I hear, as a seasoned geriatric psychiatrist, that an older pa-

tient is acting strange and confused, I ask that the urine be checked because, more often than not, a bladder

infection is the cause of sudden onset of agitation or psychosis.”

But such specialists are in short supply.

Only 50 percent of residency slots in geriatric psychiatry are filled, says Lavretsky. One problem is payment.

Most psychiatrists specializing in geriatrics are paid by Medicare, federal insurance for adults ages 65 and

up, and Medicaid, the joint federal and state health insurance program for lower-income Americans. These

programs reimburse less than private insurance does for mental health care, says Lavretsky, discouraging

new professionals — often with big student loans — from choosing this specialty.

In addition, “older adults are complicated and messy,” says psychologist Erin Emery-Tiburcio, co-director of

the Center for Excellence in Aging at Rush University Medical Center in Chicago. “There are a lot of providers

in any discipline who really aren't looking for complicated and messy.”

Older adults often have chronic physical conditions, such as heart disease or diabetes, that complicate diag-

nosis. In addition, they metabolize drugs more slowly than younger people and their bodily tissues are degen-

erating, and these effects can make medicines less effective and side effects more pronounced, says Jeste.

Moreover, cognitive decline may make it difficult for them to remember to take medications.

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There are fewer than 1,300 psychiatrists who share Lavretsky's field in the United States, and more than

half of those are concentrated in California, Florida, Massachusetts, New Jersey, New York, Pennsylvania

and Texas. Mississippi and North Dakota have no psychiatrists specializing in geriatrics, according to a 2018

analysis published in Health Affairs, a leading health policy journal.4

Psychiatrists of all specialties are also the least likely physicians to participate in Medicare. Seven percent

of psychiatrists have formally opted out of the government program, and they account for 42 percent of all

nonpediatric physicians who do not accept Medicare patients, according to an analysis by the Kaiser Family

Foundation (KFF), an organization in San Francisco that analyzes national health care issues. “This is con-

sistent with previous analyses that found that psychiatrists are less likely than other physician specialties to

accept new patients with Medicare or private insurance, suggesting that psychiatrists may prefer to be paid

directly from patients rather than insurers, to avoid the administrative burden and have the flexibility to charge

higher fees,” said KFF.5

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Possible Solutions

One solution to help close the gap is to train health care providers other than those who specialize in serving

older adults in the intricacies of delivering better care to that population. Last August, Rush University Medical

Center started a low-cost, online certificate program that teaches what mental health symptoms look like in

older adults and what therapies and services they might need. “We train primary care physicians, nurse prac-

titioners, physician assistants and health care providers of all stripes,” says Emery-Tiburcio.

Another possible solution to the shortage is a team approach. In the collaborative care model, primary care

physicians and other health care providers work with a consulting psychiatrist “to prescribe appropriate treat-

ment, including medications, and measure the patient's progress,” said Dr. Saul Levin, CEO and medical di-

rector of the American Psychiatric Association, an industry membership organization based in Washington,

D.C. This method can help psychiatrists treat many more patients.6

Lavretsky is a consulting psychiatrist to two medical practices that have adopted this model. “I love it,” she

says. One practice she works with is an integrative medicine practice with internists, rheumatologists, neu-

rologists and other specialists. The other is a multidisciplinary practice of pulmonologists, cardiologists and

neurologists that treats patients with long COVID. Besides discussing and planning the mental health care of

patients with the other physicians, she also trains the team members in the basics of geriatric psychiatry.

“Training others is key,” says Lavretsky.

Background

Early Mental Health Care

In the 19th century, citizen reformers lobbied states to open specialized hospitals to treat the mentally ill, who

were often languishing at home, in jails or in almshouses to house the poor. Their efforts were successful.

During the 1840s and 1850s, 23 public mental hospitals were constructed in 19 states, almost triple the num-

ber built in the previous two decades.7

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Nineteenth-century activist Dorothea Dix put a spotlight on the poor treatment of people

with mental illness in the nation's jails and almshouses. Decades later, local governments

would place older “senile” adults into poorly run state mental hospitals.

(Getty Images/Hulton Fine Art Collection/Contributor)

“Patients were offered exercise, work, education and religious instruction,” in such institutions, according to

one history. However, beginning in the 1860s, this “moral treatment” fell out of favor “because the curability

rate had been overestimated, the cost of facilities was high, the government curtailed funds and the public

became disillusioned with ’experts’ and their failed promises.” Instead, drugs, such as ether, were increasing-

ly used to subdue patients in state mental hospitals.8

“By the 1890s … these institutions were all under siege,” wrote nursing historian Patricia D'Antonio. The num-

ber of patients in such facilities grew exponentially as local governments, intent on saving money, removed

older residents with “senility” from local almshouses and public hospitals and sent them to state mental hos-

pitals.9

Overwhelmed, the hospitals found it difficult to provide individual therapy. By the early 1900s, they had be-

come large, impersonal institutions with poorly trained staff and limited numbers of psychiatrists, then called

alienists. The majority of patients were middle-aged or older.10

Over the next several decades, journalists' exposés, an exodus of demoralized psychiatrists from the hos-

pitals into private practice and the advent of antipsychotic drugs to control symptoms all contributed to the

release of patients from state mental hospitals to be treated in their communities, a process called deinstitu-

tionalization.11

Meanwhile, the federal government made citizens' mental health a priority, spurred initially by the poor mental

health of many veterans of World War II.

• The landmark National Mental Health Act of 1946 provided funds for research and professional train-

ing and grants to states for mental health centers and clinics. It also authorized the establishment

and construction of a National Institute of Mental Health, completed in 1949, to conduct and fund ba-

sic and clinical research into prevention and treatment of mental illness.12

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• The Mental Health Study Act of 1955 established the Joint Commission on Mental Illness and Health.

The commission's report, Action for Mental Health, described the hidden costs of mental illness and

its inadequate treatment in the United States, and included suggestions for reform, including the dis-

mantling of the system of state mental hospitals and the “invention and trial of novel approaches.”13

In response to the movement to deinstitutionalize people with mental illness, in 1963, President John F.

Kennedy signed into law the Mental Retardation Facilities and Community Mental Health Centers Construc-

tion Act. States could apply for federal grants to establish a system of community mental health centers to

treat people with mental illness within their communities rather than in mental hospitals. In 1968, Congress

expanded the role of the centers to serve older adults. But a lack of funding and a shortage of mental health

professionals meant that only 754 centers had been constructed by 1980, a little more than a third of what

was originally planned.14

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Rep. Patrick Kennedy, D-RI, speaks on the U.S. Capitol steps in March 2008 at a rally for the

Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. The legis-

lation required large group insurance plans to provide the same coverage for mental health

and addiction treatment as for surgical and medical treatments. It does not apply to

Medicare.

(AFP/Getty Images/Mandel Ngan)

Nevertheless, deinstitutionalization continued. By the 1980s, “mental hospitals and public psychiatry were

on the verge of disappearing,” wrote sociologist Andrew Scull. Yet, the promise of community-based mental

health care turned out to be a “fairy tale,” said Scull. “The decanting of mental patients into the community

… took place with virtually no advance planning or provision for the housing or other needs of those with dis-

abling mental illnesses,” he said. “The chronically mentally ill were abandoned to their fate.”15

Equal Coverage — or Not

In 1964, President Lyndon Johnson called on Congress to establish a national health care program for older

Americans. The following year, Johnson signed the Medicare and Medicaid Act, also known as the Social

Security Amendments of 1965, into law, “providing hospital, post-hospital extended care, and home health

coverage to Americans aged 65 or older … receiving retirement benefits from Social Security or the Railroad

Retirement Board.”16

In 1978, a group of 11 psychiatrists formed the American Association for Geriatric Psychiatry “as interest in

mental health and the process of aging grew, and older adults were increasing in number and as a percent-

age of the U.S. population,” according to the membership organization's website.17

In 1992, Congress established the Substance Abuse and Mental Health Services Administration (SAMHSA).

It “leads public health efforts to advance the behavioral health of the nation and to improve the lives of indi-

viduals living with mental and substance use disorders, and their families,” according to its website.18

In 2008, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity

Act, expanding the protections provided by the Mental Health Parity Act of 1996, which said that large group

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health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable

than any such limits imposed on medical and surgical benefits. The law requires health insurance plans that

offer mental health coverage to ensure that treatment limits as well as deductibles, copayments, coinsurance

and out-of-pocket limits on these benefits are no more restrictive than those on medical and surgical bene-

fits.19

The law does not apply to Medicare. Another law, the Medicare Improvements for Patients and Providers Act

of 2008, required that a patient's share of costs for outpatient mental health services under Medicare match

the patient cost sharing for outpatient medical treatment, according to the Kaiser Family Foundation. But that

left treatment limits, such as the number of days allowed in hospital, without parity protection.

Medicare imposes a lifetime limit of 190 days of inpatient care at psychiatric hospitals. There is no such life-

time limit on hospitalization for other medical conditions. “People who receive Medicare benefits in inpatient

psychiatric facilities often have a diagnosis of schizophrenia, bipolar disorder or major depressive disorder —

conditions that typically require ongoing treatment and multiple hospitalizations over the course of a lifetime,”

according to the National Alliance on Mental Illness, a grassroots advocacy organization based in Arlington,

Va., which calls the lifetime limit discriminatory and would like to see it repealed.20

The COVID-19 pandemic spurred other changes to Medicare. Before the pandemic, Medicare coverage of

telehealth services for all medical conditions was limited. Medicare covered telehealth visits only for benefi-

ciaries living in rural areas, and patients had to access the services from a clinic or doctor's office.

But once the pandemic began in 2020, Congress temporarily allowed Medicare patients living anywhere in

the country to use telehealth and to do so from home. It also approved coverage of audio-only health visits,

which is important for Medicare patients without a computer, broadband connection or the skills to use a com-

puter to communicate with their health care providers and for those who prefer the phone. Use of telehealth,

including for mental health services, surged in 2020, and then subsided but remained above prepandemic

levels.21 Meanwhile, in October 2022, the Biden administration announced plans to allocate $1.2 billion in

grants for 24/7 behavioral health clinics across the country.22

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Current Situation

Medicare Changes

Even for those without access to such clinics, mental health care under Medicare has gotten easier this year

— for patients and some professionals.

Licensed professional counselors and licensed marriage and family therapists no longer need to be under the

direct supervision of medical personnel to provide mental health services to Medicare beneficiaries. Previous-

ly, a doctor or member of other Medicare-approved professional categories had to be present in the office.

These include, among others, psychiatrists, clinical psychologists, nurse practitioners and physician assis-

tants. But starting this year, a rule change allows counselors and therapists to provide these services under

general supervision, which means the supervisors no longer need to be in the building.23

In addition, starting in 2024, counselors and marriage and family therapists will be allowed to directly bill

Medicare, as part of an omnibus funding bill, the Consolidated Appropriations Act, 2023, enacted into law

in December. Currently, the supervising medical professional bills Medicare and then pays the counselor or

therapist.24

By making it easier for counselors and therapists to see Medicare patients, these changes “will increase the

number of qualified providers that Medicare beneficiaries can see and potentially help alleviate some work-

force shortage issues, particularly in rural and underserved areas,” says Meredith Freed, a senior policy ana-

lyst at the Kaiser Family Foundation.

“It is a really helpful change,” says Zerden of the Carolina Health Workforce Research Center. “But there are

still going to be kinks in the system, and just because a lever gets turned on, it doesn't necessarily mean that

instantly people are seen.”

Some marriage and family therapists and counselors may have a full slate of patients and no room for more,

says Zerden. In addition, primary care physicians, who are often the first stop for older Americans with men-

tal health needs, may not be aware of these Medicare changes and that a new class of providers are more

readily available to provide counseling to their patients.

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A National Institute of Mental Health website addresses some signs of deteriorating mental

health to look for in older Americans and encourages visiting a health care provider for

those with symptoms of depression or anxiety. Raising awareness in the medical profes-

sion that depression is not a normal part of aging will help older Americans receive the

proper care.

(Screenshot/National Institute of Mental Health Website)

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“If you're a busy primary care physician, you might not have the resources or bandwidth to really keep up with

that,” says Zerden.

Congress and Medicare are also making telehealth mental health services permanently more accessible. As

part of the December omnibus funding bill, Congress extended the pandemic-era telehealth waivers through

December 31, 2024. It went even further for telehealth mental health services, permanently removing the re-

striction that telehealth is only for rural residents and the requirement that telehealth be accessed at a clinic

or doctor's office. A year earlier, Medicare had changed its rules to permanently allow audio-only therapy for

mental health and substance use disorders.25

However, starting in 2025, there will be in-person requirements for using telehealth for all kinds of health

problems, including mental health, says Freed. A patient must see a physician in person six months prior to

initiating telehealth and then once a year thereafter.

Training Efforts

The American Association of Geriatric Psychiatry (AAGP), in collaboration with the American Board of Psy-

chiatry and Neurology, has begun a pilot program to train and certify general psychiatrists in the management

of mental health disorders in older adults, says AAGP president-elect Lavretsky. “Our job is to develop the

curriculum,” she says.

The association currently offers its members a review course in how to manage bipolar, anxiety, substance

use and sleep disorders in older adults, among other skills. But the association is well aware that its members,

who are relatively few in number, cannot fully meet the needs of the country's growing older population alone,

says Lavretsky. So it is revising the curriculum for nonspecialist psychiatrists.26

In the future, the association plans to create a certification program for nurse practitioners and other pro-

fessionals who work in long-term care facilities, nursing homes and rehabilitation centers managing mental

health disorders in older adults.

“These are skills that can be taught,” says Lavretsky. “That's where the solution will be over the next 10 years.”

In addition, Lavretsky would like to see states require that physicians be trained in the mental health needs

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of older adults. Each state's medical licensing board has its own continuing education requirements for physi-

cians to retain their license to practice. Most boards, if not all, require that physicians take courses in end-of-

life care and in pain management, Lavretsky says. “They could require a similar kind of additional training in

geriatric care for local licensure renewals.”

Short Features

č Show All

Bias Harms Older Adults' Mental Health

Ageism can cause problems such as depression and impede effective help

Nine years ago, poet and writer Anne Whitehouse lost her job of nearly 18 years. She suspects it was be-

cause of her age. Whitehouse, a New Yorker, was 60 years old at the time and writing for a nonprofit. Her

colleagues were much younger.

“The executive director who let me go wasn't the one who hired me,” says Whitehouse, adding that she

thought he was not a good judge of writing and did not appreciate the quality of her work. She speculates

that he could replace her with someone younger whom he could pay less.

Whitehouse complained and received a small settlement, although the company said it did not base its de-

cision on age discrimination. “I was very depressed for months,” says Whitehouse. “I felt really rejected.”

She sought counseling and says it helped put the experience in perspective. “It's just a job. That's what I

always remind myself.”

Erin Emery-Tiburcio, a clinical psychologist at Rush University in Chicago and the chair of the American

Psychological Association's Committee on Aging, says ageism is common in our society. “It's everywhere,”

she says, referring to all kinds of ageism, from workplace discrimination to assumptions that older adults

cannot operate technology to everyday messages that aging is bad.

Emery-Tiburcio points to the racks of birthday cards poking fun at aging, the pervasive advertisements for

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anti-aging cosmetics and even the federal government's dependency ratio, which adds the number of chil-

dren under age 15 and the number of adults aged 65 and older and compares the result to the number of

U.S. working-age adults.1

“These messages are telling us that we should avoid aging at all costs, and by extension, [that] those who

are older lack worth and should be marginalized,” says Emery-Tiburcio.

Research shows that ageism can affect the mental health of older adults.

In one study published in the JAMA Network Open in 2022, health researchers analyzed a survey of more

than 2,000 U.S. adults between the ages of 50 and 80 about their encounters with everyday ageism. The

survey polled participants using a 10-point scale divided into three categories: ageist messages, as in an-

ti-wrinkle cream advertisements; interpersonal interactions, as when someone assumes an older person

has nothing to do all day; and internalized ageism, when older adults themselves believe prejudices about

aging, such as that loneliness is inevitable.2

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Activist Ashton Applewhite holds a copy of her book, This Chair Rocks: A Manifesto

Against Ageism, during a 2020 conference in San Jose, Calif. Bringing attention to the vi-

brancy of older Americans and the perniciousness of stereotypes about aging can help

break down negative self-perceptions and improve health outcomes for older Americans.

(Getty Images/Watermark Conference for Women/Marla Aufmuth)

“We found that more than 93 percent of this nationally representative sample reported that they experi-

enced one or more forms of these different types of everyday ageism … on a fairly regular basis,” says lead

author Julie Ober Allen, assistant professor of health promotion at the University of Oklahoma. Internalized

ageism was the most common category indicated by respondents.

“We find that the people who report higher scores on the everyday ageism scale are much more likely

to report poorer or fair self-rated health and also are much more likely to report some sort of depressive

symptoms,” Allen says.

It is possible that people who are in poor physical or mental health experience more ageism than healthier

people. But the causality also runs the other way because ageism acts as a source of chronic stress, says

Allen. “These types of repeated offenses, where you are not seen as an individual, you are not seen as

valuable, can start to put a lot of wear and tear on someone's mental health.”

Health care providers are not immune to exhibiting ageism. Research shows that they screen older adults

for mental health issues less often than younger adults, and that even when older adults are screened,

they are offered psychotherapy less often, says Emery-Tiburcio.3 Physicians not trained in geriatrics may

conclude that “depression or anxiety are normal parts of aging,” she says, adding, “That is ageism.”

The way health care providers speak to older patients can also reflect ageism, said Becca Levy, an ageism

researcher and professor at the Yale School of Public Health. Health care providers often use patronizing

language and tone, referred to as elderspeak, and research shows that the practice can reinforce a pa-

tient's own negative beliefs about aging, said Levy.4

Ageism also leads to higher health care costs for society, according to Levy. She and a group of Yale col-

leagues studied the effect of ageism on eight high-cost health conditions in the United States, from cardio-

vascular disease to diabetes to mental disorders, in Americans aged 60 years and older.

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Through a complicated set of analyses, they found that in a one-year period, age discrimination, negative

age stereotypes and negative self-perceptions of aging led to 2,650,849 cases of mental disorders in older

adults, necessitating $8.4 billion dollars in health care costs. “This study helps to give visibility to the dam-

aging results of ageism,” wrote Levy and colleagues.5

It makes a strong case for intervention, they said, noting that experimental research has shown that expos-

ing people to more positive depictions of aging can help reduce negative age-related stereotypes and neg-

ative self-perceptions of aging and improves health. “A comprehensive approach would involve addressing

the societal sources of injurious images about and behaviors toward the old …” and “would require a large-

scale campaign,” Levy and her colleagues wrote.6

Allen agrees. “We need wide-ranging social change about attitudes toward older adults,” she says. “We

need more diverse role models, more exposure in the media to the diversity within the older adult popula-

tion … in terms of employment status, health status and so many different factors.”

—

• Barbara Mantel

1.

Luke Rogers and Kristie Wilder, “Shift in Working-Age Population Relative to Older and Younger Amer-

icans,” the U.S. Census Bureau, June 25, 2020, https://www.census.gov/library/stories/2020/06/working-

age-population-not-keeping-pace-with-growth-in-older-americans.html.

2.

Julie Ober Allen et al., “Experiences of Everyday Ageism and the Health of Older US Adults,” JAMA Net-

work Open, June 15, 2022, https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2793359.

3.

Donovan T. Maust, Helen C. Kales and Frederic C. Blow, “Mental Health Care Delivered to Younger and

Older Adults by Office-Based Physicians Nationally,” Journal of the American Geriatrics Society, July 3,

2015, https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.13494.

4.

Becca R. Levy, “The Role of Structural Ageism in Age Beliefs and Health of Older Persons,” JAMA Network

Open, Feb. 9, 2022, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788860.

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5.

Becca Levy et al., “Ageism Amplifies Cost and Prevalence of Health Conditions,” The Gerontologist, Nov.

13, 2018, pp. 176, 179–180, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182003/.

6.

Ibid., pp. 178–179.

Outlook

Enduring Issues

Blazer of Duke University is certain that government funding for mental health research and improving mental

health care will increase in the next decade, as a growing number of public figures frankly discuss their ex-

periences with mental health disorders and raise awareness. “However … the focus is on substance use dis-

orders, children and stress-related conditions, such as burnout in the workplace,” Blazer says. Nevertheless,

he is hopeful that care for older adults can ride this wave and gain greater visibility and resources.

The Center for Excellence in Aging's Emery-Tiburcio expects shortages of mental health care professionals

who specialize in treating people aged 65 and above to persist. “I don't have high hopes that we're ever going

to have enough specialists or even make a significant difference in moving the needle,” she says. “This is why

I feel strongly, as my profession does as a whole, that we need to be doing a lot more education of general-

ists,” such as primary care physicians and physician assistants.

Freed of the Kaiser Family Foundation says it is difficult to predict whether the changes in Medicare will have

the desired impact on workforce shortages of mental health providers who treat older adults. “We'll only see

how it plays out in time,” she says.

Lavretsky says large health systems and practices will continue to substitute nurse practitioners and physician

assistants for psychiatrists to reduce costs and address shortages. “They have one psychiatrist and then sev-

eral nurse practitioners, for example, to serve patients, and that's becoming more common.”

Meanwhile, Neil McLachlan and his sister, Ruth, have decided to take their father to another neurologist when

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both parents return to Virginia for the warmer months. After Ruth visited and observed their father earlier this

month, the siblings now think depression could be the problem, and are wondering if insomnia might be the

trigger because sleep disturbances can raise the risk of depression. As a first step, the neurologist will con-

duct a sleep study.27

“We're going to take some action and see what happens,” says McLachlan. “We have a plan.”

This article was written with the support of a journalism fellowship from The Gerontological Society of Ameri-

ca, The Journalists Network on Generations and The Commonwealth Fund.

Pro/Con

Should traditional Medicare cover hearing aids to help older adults' mental health?

č Show All

Pro

Max Richtman

President & CEO, National Committee to Preserve Social Security and Medicare. Written for CQ Re-

searcher, March 2023

Traditional Medicare (not just some Medicare Advantage plans) should offer basic hearing care coverage,

including hearing aids. Some 30 percent of adults over age 65 have some degree of age-related hearing

loss. Unfortunately, Medicare does not yet provide this coverage, even though good hearing is crucial to

seniors' overall well-being and mental health. Untreated hearing loss in older people can lead to earlier

onset of dementia, depression, anxiety, balance problems, falls and social isolation.

According to the National Institutes of Health, “Older people who can't hear well may become depressed or

withdrawn from others because they feel frustrated or embarrassed about not understanding what is being

said.” No seniors should feel isolated, confused or shut out from the world because they can't get proper

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hearing care. But without insurance coverage, many seniors on fixed incomes simply cannot pay $1,000 to

$5,000 for hearing aids.

Some argue that Medicare cannot afford to cover hearing aids and hearing services. But since untreated

hearing loss is a significant risk factor for dementia, and is linked to depression and falls, the costs of doing

nothing is staggering. In 2020, Medicare and Medicaid spent $206 billion caring for people with dementias.

In 2050, that cost is expected to be $777 billion. Improving the health outcomes of seniors by treating hear-

ing loss could save billions of dollars.

We support the Medicare Hearing Aid Coverage Act reintroduced by Reps. Debbie Dingell, D-Mich., and

Brian Fitzpatrick, R-Pa., which would expand the program to cover hearing aids. “Hearing aids aren't a lux-

ury,” Dingell said. “They are critical for millions of people to maintain a healthy, independent lifestyle.”

Meanwhile, seniors are getting some relief thanks to an executive order from President Biden and a re-

cently issued Food and Drug Administration rule allowing adults with mild to moderate hearing loss to buy

over-the-counter hearing aids without a prescription, exam or audiologist fitting. This provides significant

breathing room for Americans with hearing loss. But it is not the kind of comprehensive expansion that

Medicare beneficiaries ultimately need.

It is past time to expand traditional Medicare to include this fundamental coverage for older Americans.

Such a move would benefit 40 million Americans with hearing loss, and a raft of innovative companies that

are ready and willing to expand, enter and compete in a more robust hearing aid marketplace.

Con

Joseph Antos

Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute. Written

for CQ Researcher, March 2023

Nearly a third of seniors suffer from hearing loss, yet few have ever used a hearing aid. The primary barrier:

cost. A pair of hearing aids typically runs between $2,000 and $7,000. Traditional Medicare does not cover

this expense. Adding a hearing benefit to Medicare would cost the program about $37 billion over the next

decade. There are already better options for seniors with age-related hearing loss.

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Recent changes in federal rules have opened the door to new over-the-counter products with a broader

range of features and lower cost than traditional hearing aids. The 2017 Over-the-Counter Hearing Aid Act

broke the regulatory log jam that limited the types of hearing aids available to consumers. The regulation

issued last August creates a new category of nonprescription hearing aids for people with mild to moderate

hearing loss.

For the first time, hearing aids can now be purchased directly by consumers online and at retail stores with-

out a prescription. A recent survey by the National Council on Aging found that prices for those products

vary from $99 to nearly $3,000 a pair, depending on their features.

Medicare beneficiaries also have the option of enrolling in a Medicare Advantage (MA) plan that covers

hearing aids. The Kaiser Family Foundation reports that nearly all MA enrollees have access to hearing

benefits. About 40 percent of enrollees are in plans with an annual limit on hearing coverage averaging

$960 a year. Seniors with serious hearing problems are likely to enroll in more generous plans to avoid

such limits.

Even with new over-the-counter options and MA, the cost of hearing aids could be beyond the reach of

some seniors. But adding hearing aid coverage to traditional Medicare would still leave beneficiaries with

substantial out-of-pocket costs.

That's because prescription hearing aids would be covered under Medicare Part B, which requires benefi-

ciaries to pay 20 percent of the cost. Most seniors with moderate hearing loss would pay less by purchasing

an over-the-counter device instead of a prescription hearing aid. Those with more serious hearing deficits

could expect to pay $1,000 or more for a prescription hearing aid, even with Medicare coverage.

The time for adding hearing aids to Medicare coverage has passed. Medicare is facing an imminent fiscal

crisis as spending outpaces revenue. Our larger concern should be to ensure that current benefits remain

funded before we make more promises that we will not be able to keep.

Here are some issues to consider about aging and mental health in America:

Discussion Questions ğ

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Chronology

1840s–1930s

States build public mental hospitals; overcrowding soon becomes an issue.

• Why are doctors less likely to screen older adults for mental illness, or suggest mental

health care?

• What are some ways to address the shortage in knowledgeable mental health care pro-

fessionals to help older adults as more Baby Boomers retire?

• How does ageism contribute to mental health challenges for older adults?

• Why might older adults have fewer mental health issues than their younger counter-

parts?

• In addition to treatment, what are some ways society can help combat stressors that can

worsen mental health in older adults?

1843

Mental health activist Dorothea Dix denounces conditions experienced by people with

mental illness in U.S. jails and poor houses and crusades for public mental hospitals.

1860

Twenty-three public mental hospitals are built; over the next several decades, local gov-

ernments shift older “senile” adults into state mental hospitals, straining medical and fi-

nancial resources.

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1940s–1950s

Groundwork is laid for deinstitutionalization of people with mental illness.

1909

The National Committee for Mental Hygiene is founded; it compiles statistics about men-

tal illness and focuses on mental health problems in the armed services during World

War I.

1930

The first International Congress on Mental Hygiene convenes; members of the mental

hygiene movement believe that childhood delinquency and conflicts in school and at

home contribute to mental illness and that mental health principles should be integrated

into education, social work, nursing, public health, industry and government.

1946

Life magazine publishes an exposé of deplorable conditions in many state mental hospi-

tals…. The National Mental Health Act prepares for the creation of the National Institute

of Mental Health in 1949.

1950

The number of Americans aged 65 and older reaches 12 million, or 8.1 percent of the

population, more than doubling from 3.1 million and 4 percent in 1900, according to U.S.

Census data; only one in eight older adults has health insurance…. During the decade,

California and New York pass laws establishing community mental health clinics.

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1960s–1980s

Federal laws empty public mental hospitals, as new drugs revolutionize treatment.

1952

The American Psychiatric Association publishes the Diagnostic and Statistical Manual of

Mental Disorders (DSM), which classifies mental disorders and is used by clinicians to

diagnose patients.

1955

The Mental Health Study Act of 1955 establishes the Joint Commission on Mental Illness

and Health; its report, “Action for Mental Health,” describes the inadequate treatment of

mental illness and suggests reforms, including dismantling state mental hospitals.

1956

The pharmaceutical market introduces the first tricyclic antidepressant to treat clinical

depression, but it can lead to blood pressure changes in older adults, contributing to falls

and fractures.

1963

Older adults number 17.5 million, or 9.4 percent, of the U.S. population…. The Mental

Retardation Facilities and Community Mental Health Centers Construction Act provides

grants to states to establish community mental health centers to serve deinstitutionalized

people with mental illness.

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1990s–present

Congress promotes mental health parity in private insurance; Medicare lifts restrictions on tele-

health for mental health.

1965

Medicare, the newly created federal health insurance program for older adults, pays for

treatment of acute mental illness in general and private psychiatric hospitals. States, to

save costs, shift many older individuals with mental illness out of public mental hospitals

into these facilities.

1968

Congress expands role of community mental health centers to serve children and older

adults.

1980

Only 754 community mental health centers have been built, far short of the projected

2,000.

1988

Prozac, the first selective serotonin reuptake inhibitor, or SSRI, is introduced, transform-

ing depression treatment; it is safer and better tolerated by older adults that previous

drugs.

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1996

Congress passes the Mental Health Parity Act, which restricts large group health insur-

ance plans from placing lower dollar caps on mental health benefits than on physical

health benefits.

2008

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act

expands parity significantly for large group plans…. The Medicare Improvements for Pa-

tients and Providers Act equalizes Medicare patients' share of costs for outpatient men-

tal health services and outpatient medical treatment; it leaves treatment limits for men-

tal illness without parity protection…. The U.S. Food and Drug Administration requires

a black box warning on all antipsychotic medications about the increased risk of stroke

and death in older adults with dementia.

2010

The Patient Protection and Affordable Care Act extends parity to individual and small

group plans purchased through newly created state insurance exchanges.

2020

During the pandemic emergency, Medicare temporarily lifts restrictions that had limited

telehealth to rural residents who accessed the services from a clinic or doctor's office.

2022

Medicare make the temporary lifting of telehealth restrictions permanent, but only for

mental health services.

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System.Collections.Generic.List`1[SCP.Web.Services.GenericContent.TabbedContent.Reports.ShortFea-

tureViewModel]

Bibliography

Books

Hantke, Nathan, AmitEtkin and RuthO'Hara (eds.), Handbook of Mental Health and Aging: Third Edition,El-

sevier, 2020. Professors of neurology and psychiatry collect considerations of cultural and physical factors

affecting mental illness in older adults.

Insel, Thomas,Healing: Our Path from Mental Illness to Mental Health,Penguin Press, 2022. A former director

of the National Institute of Mental Health offers a comprehensive plan for the country's failing mental health

system.

Riley, Alex,A Cure for Darkness: The Story of Depression and How We Treat It,Scribner, 2021. A science

writer charts the diagnosis of depression from ancient Greece to experimental remedies of the future.

Scull, Andrew,Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness,Harvard University

Press, 2022. A sociology professor emeritus at the University of California, San Diego, traces two hundred

years of America's battle with mental illness.

2023

Medicare makes it easier for licensed professional counselors and marriage and family

therapists to provide therapy to older adults (January)…. The Biden administration re-

leases its mental health research priorities, which include, among others, increasing ac-

cess to mental health interventions, improving treatment for serious mental illness and

expanding the mental health workforce (February).

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Articles

Fleet, Alexa,et al.,“Improving Behavioral Health Care For Older Americans: If Not Now, When?,”Health

Affairs, June8,2022, https://www.healthaffairs.org/content/forefront/improving-behavioral-health-care-older-

americans-if-not-now. Mental health needs of older adults are often not identified or addressed, but there are

workable strategies to overcome barriers to care.

Pela, Robrt L.,“Are Older Adults More Open to Discussing Their Mental Health?”Next Avenue, May16,2022,

https://www.nextavenue.org/is-the-mental-health-stigma-decreasing-for-older-adults/. In a recent survey, old-

er adults said they are more willing to seek out mental health care than prior to the COVID-19 pandemic.

Roth, Alisa,“The Truth About Deinstitutionalization,”The Atlantic, May25,2021, https://www.theatlantic.com/

health/archive/2021/05/truth-about-deinstitutionalization/618986/. A journalist argues that the theory that the

closing of state psychiatric hospitals led to the increased incarceration of people with mental illness is flawed.

Sanger-Katz, Margot,“The December Omnibus Bill's Little Secret: It Was Also a Giant Health Bill,”The

New York Times, Jan.22,2023, https://www.nytimes.com/2023/01/22/upshot/new-health-policies-budget.html.

Congress passed legislation on mental health, drugs and pandemic preparedness, including extending loos-

ened telehealth rules beyond the COVID-19 emergency.

Reports and Studies

Fields, Eric C.,et al.,“With age comes well-being: older age associated with lower stress, negative affect

and depression throughout the COVID-19 pandemic,”Aging and Mental Health, Dec.16,2021, p. 2071,

https://pubmed.ncbi.nlm.nih.gov/34915781/. Older adults fared better than younger people in a survey of

mental health symptoms during the pandemic.

Freed, Meredith, JulietteCubanski and TriciaNeuman,“FAQS on Mental Health and Substance Use Disorder

Coverage in Medicare,”Kaiser Family Foundation, Jan.18,2023, https://www.kff.org/medicare/issue-brief/

faqs-on-mental-health-and-substance-use-disorder-coverage-in-medicare/. Congress and Medicare made

permanent the temporary lifting of restrictions during the pandemic on telehealth for mental health care.

Ochieng, Nancy, KarynSchwartz and TriciaNeuman,“How Many Physicians Have Opted-Out of the Medicare

Program?”Kaiser Family Foundation, Oct.22,2020, https://www.kff.org/medicare/issue-brief/how-many-physi-

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cians-have-opted-out-of-the-medicare-program/. Psychiatrists account for almost half of physicians who opt

out of serving Medicare patients, adding to the difficulty of older Americans to access mental health services.

Reynolds, Charles F.3rd, et al.,“Mental health care for older adults: recent advances and new directions

in clinical practice and research,”World Psychiatry, Sept.8,2022, https://onlinelibrary.wiley.com/doi/10.1002/

wps.20996. Experts in geriatrics say multidisciplinary teams should be providing mental health care to older

adults, a growing segment of the population.

Vespa, Jonathan, LaurenMedina and David M.Armstrong,“Demographic Turning Points for the United States:

Population Projections for 2020 to 2060,”U.S. Census Bureau, February2020, https://www.census.gov/con-

tent/dam/Census/library/publications/2020/demo/p25-1144.pdf. By 2034, adults aged 65 and above will out-

number children for the first time in U.S. history, according to projections from the U.S. Census Bureau.

Webb, Lauren M., and Christina Y.Chen,“The COVID-19 pandemic's impact on older adults' mental health:

Contributing factors, coping strategies and opportunities for improvement,”International Journal of Geriatric

Psychiatry, Nov.15,2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8646312/. Younger generations re-

ported higher rates of anxiety and depression during the COVID-19 pandemic compared to older adults.

The Next Step

Ageism

Ang, Adam,“AI can ’exacerbate’ ageism in aged care: study,”Healthcare IT News, March13,2022,

https://tinyurl.com/4hpapmc3. A study revealed that the use of artificial intelligence (AI) in long-term care set-

tings can intensify ageism unless more inclusive technology is developed.

Mann, Denise,“Ageism is everywhere and can affect physical, mental health,”UPI, June21,2022,

https://tinyurl.com/2s3frkau. Age-related discrimination can lead to detrimental physical and mental health

outcomes, such as depression or other chronic conditions.

Senz, Kristen,“The impact of ageism on health and health care: A research roundup and explainer,”The Jour-

nalist's Response, Nov.14,2022, https://tinyurl.com/4ksb9a7z. New research suggests that ’everyday ageism’

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can lead to health issues such as chronic stress; federal and state officials hope to combat such bias.

Medicare

Fullen, Emma,“Bill passage ’opens floodgates’ for mental-health care for aging individuals,”Star Press,

March13,2023, https://tinyurl.com/5h68utpa. The 2023 omnibus appropriations bill and the Mental Health Ac-

cess Improvement Act will provide Medicare beneficiaries, such as seniors, with access to more mental health

services.

Lovett, Laura,“New Bill Looks to Expand Access to Mental Health Services for Seniors,”BH Business,

Dec.16,2022, https://tinyurl.com/mwsfcy8v. Reintroduced in 2023, the bipartisan Increasing Mental Health

Options Act of 2022 seeks to ensure that Medicare beneficiaries have access to psychologists and other

mental health services.

Sink, Justin, and JoshWingrove,“Biden Eyes Tax Hike on Income Over $400,000 to Fund Medicare

(1),”Bloomberg Law, March7,2023, https://tinyurl.com/3pdmrekx. President Biden will pursue a tax increase

and renegotiate drug prices to secure funding for Medicare, but such efforts will likely face criticism as Re-

publicans control the House.

Mental Health Parity

Bernstein, Lenny,“Equal mental health coverage elusive despite legal guarantee,”The Washington Post,

June2,2022, https://tinyurl.com/bddsepkc. Unequal insurance coverage deprives certain individuals of access

to behavioral health services, exacerbating the U.S. mental health crisis.

Kelly, Susan,“States need help to enforce mental health parity laws, report finds,”Healthcare Dive,

Oct.17,2022, https://tinyurl.com/3tn4dy5r. The Georgetown University Health Policy Institute found that state

insurance departments need greater federal support to ensure insurer compliance with the Mental Health Par-

ity and Addiction Equity Act of 2008, which requires insurance to cover mental health conditions at the same

level as coverage of other physical health conditions.

Larson, Chris,“’I Don't Think This Is Over’: Reactions to the Latest in Wit v. United Behavioral Health,”BH Busi-

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ness, Feb.13,2023, https://tinyurl.com/3xsyjcp7. The Court of Appeals undid a favorable 2019 district court

decision that determined how behavioral health claims were handled by payers.

Mental Illness in Seniors

Baruchman, Michelle,“Older people are often invisible in mental health settings. Here are some tips to get

care,”The Seattle Times, Feb.9,2023, https://tinyurl.com/2p99beru. Because of their age, mental health con-

cerns among older people may be more likely to be dismissed by health care providers, but advice such as

challenging ageist stereotypes can help seniors get the support they need.

Gavin, Kara,“Loneliness Is Down Among Older Adults But Still Too High,”Futurity, March14,2023,

https://tinyurl.com/mj2634k5. Rates of loneliness have decreased among older adults since the pandemic's

early days, but social isolation still remains an urgent issue that can affect physical and mental health.

Graham, Judith,“Older people with anxiety frequently don't get help. Here's why,”CNN, March6,2023,

https://tinyurl.com/2p8tp69h. Despite being the most common psychological disorder among adults, anxiety

can be difficult to identify in people 65 and older, which prevents that age group from receiving diagnosis and

treatment.

Contacts

American Association of Geriatric Psychiatry, 6728 Old McLean Village Dr.McLeanVA22101;703-884-9453;

http://aagponline.org A membership association of geriatric psychiatrists and other health care professionals.

American Psychiatric Association, 202-559-3900; http://psychiatry.org A membership organization that pro-

motes access to mental health care and advocates for the profession of psychiatry in the United States.

American Psychological Association, 750 First St., N.E.WashingtonDC20002;800-374-2721; http://apa.org A

scientific and professional organization representing psychology in the United States.

Center for Excellence in Aging, Rush University Medical Center, 1653 W. Congress ParkwayChica-

goIL60612;312-942-7070; http://aging.rush.edu Advances care for older adults and their families through clin-

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ical services, research, education, community outreach and advocacy.

Centers for Disease Control and Prevention, 1600 Clifton RoadAtlantaGA30329;800-232-4636; http://cdc.gov

The federal agency that fights disease; also houses the National Center for Health Statistics.

The Henry J. Kaiser Family Foundation, 185 Berry St., Ste. 2000San FranciscoCA94107;650-854-9400;

http://kff.org A nonprofit source of research, facts and analysis on national health policy issues.

National Alliance on Mental Illness, 4301 Wilson Blvd., Ste. 300ArlingtonVA22203;703-524-7600; http://na-

mi.org A grassroots organization advocating for Americans affected by mental illness.

Program on Health Workforce Research and Policy, University of North Carolina at Chapel Hill, 725 Martin

Luther King Jr. Blvd.Chapel HillNC27599;919-966-5011; http://shepscenter.unc.edu/programs-projects/work-

force Conducts studies to inform health workforce policy at national, state and regional levels.

Footnotes

1. Jonathan Vespa, Lauren Medina and David M. Armstrong, “Demographic Turning Points for the United

States: Population Projections for 2020 to 2060,” U.S. Census Bureau, February 2020, https://www.cen-

sus.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf.

2. Lauren M. Webb and Christina Y. Chen, “The COVID-19 pandemic's impact on older adults' mental health:

Contributing factors, coping strategies, and opportunities for improvement,” International Journal of Geri-

atric Psychiatry, Nov. 15, 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8646312/; “Interactive Sum-

mary Health Statistics for Adults — 2019–2021,” National Center for Health Statistics, Centers for Disease

Control and Prevention, https://wwwn.cdc.gov/NHISDataQueryTool/SHS_adult/index.html.

3. Eric C. Fields et al., “With age comes well-being: older age associated with lower stress, negative affect

and depression throughout the COVID-19 pandemic,” Aging and Mental Health, Dec. 16, 2021, p. 2071,

https://pubmed.ncbi.nlm.nih.gov/34915781/.

4. Alexa Fleet et al., “Improving Behavioral Health Care For Older Americans: If Not Now, When?,” Health

Affairs, June 8, 2022, https://www.healthaffairs.org/content/forefront/improving-behavioral-health-care-older-

americans-if-not-now.

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5. Nancy Ochieng, Karyn Schwartz and Tricia Neuman, “How Many Physicians Have Opted-Out of the

Medicare Program?” Kaiser Family Foundation, Oct. 22, 2020, https://www.kff.org/medicare/issue-brief/how-

many-physicians-have-opted-out-of-the-medicare-program/.

6. Barbara Mantel, “Youth Mental Health,” CQ Researcher, July 1, 2022.

7. Barbara Mantel, “Mental Health Policy,” CQ Researcher, May 10, 2013.

8. ”From Quackery to Bacteriology, Document 5: Mental Health,” University of Toledo Libraries,

https://www.utoledo.edu/library/canaday/exhibits/quackery/quack5.html.

9. Patricia D'Antonio, “History of Psychiatric Hospitals,” Nursing, History and Health Care, 2011,

https://www.nursing.upenn.edu/nhhc/nurses-institutions-caring/history-of-psychiatric-hospitals/.

10. Mantel, “Mental Health Policy,” op. cit.; Alisa Roth, “The Truth About Deinstitutionalization,” The Atlantic,

May 25, 2021, https://www.theatlantic.com/health/archive/2021/05/truth-about-deinstitutionalization/618986/.

11. Mantel, “Mental Health Policy,” op. cit.

12. Ellen Herman, The Romance of American Psychology: Political Culture in the Age of Experts (1995),

pp. 245–247, https://publishing.cdlib.org/ucpressebooks/view?do-

cId=ft696nb3n8&chunk.id=d0e5267&toc.depth=100&brand=ucpress.

13. “Statement on report of Joint Commission on Mental Illness and Health,” American Psychologist, 1963,

https://psycnet.apa.org/record/1964-01176-001.

14. Mantel, “Mental Health Policy,” op. cit.

15. Andrew Scull, Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness (2022), pp. 247,

288.

16. “Medicare & Medicaid: Milestones 1937–2015,” Centers for Medicare & Medicaid Services,

https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Mile-

stones-1937-2015.pdf.

17. “History,” American Association for Geriatric Psychiatry, https://www.aagponline.org/about-aagp/history/.

18. “About Us,” Substance Abuse and Mental Health Services Administration, https://www.samhsa.gov/about-

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us/who-we-are.

19. Kaye Pestaina, “Mental Health Parity at a Crossroads,” Kaiser Family Foundation, Aug. 18, 2022,

https://www.kff.org/private-insurance/issue-brief/mental-health-parity-at-a-crossroads/; The Mental Health

Parity and Addiction Equity Act (MHPAEA), Centers for Medicare and Medicaid Services, accessed March

15, 2023, https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea.

20. “Medicare 190-day Lifetime Limit,” National Alliance on Mental Illness, https://www.nami.org/Advocacy/

Policy-Priorities/Improving-Health/Medicare-190-Day-Limit.

21.Ibid.; Barbara Mantel, “Telemedicine in the Time of COVID-19,” Rural Health Quarterly, Nov. 23, 2020,

http://ruralhealthquarterly.com/home/2020/11/23/telemedicine-in-the-time-of-covid-19/.

22. Amanda Seitz, “Biden administration seeks to expand 24/7 mental health care,” The Associated Press,

Oct. 18, 2022, https://www.pbs.org/newshour/health/biden-administration-seeks-to-expand-24-7-mental-

health-care.

23. Meredith Freed, Juliette Cubanski and Tricia Neuman, “FAQS on Mental Health and Substance Use Dis-

order Coverage in Medicare,” Kaiser Family Foundation, Jan. 18, 2023, https://www.kff.org/medicare/issue-

brief/faqs-on-mental-health-and-substance-use-disorder-coverage-in-medicare/.

24.Ibid.

25. “FAQS on Mental Health and Substance Use Disorder Coverage in Medicare,” op. cit.

26. “AAGP 2022 Geriatric Psychiatry Review Course On Demand,” American Association for Geriatric Psy-

chiatry, Sept. 22, 2022, https://www.aagponline.org/course/aagp-2022-geriatric-psychiatry-review-course-on-

demand/.

27. “Depression and Sleep: Understanding the Connection,” Johns Hopkins Medicine, accessed March 15,

2023, https://www.hopkinsmedicine.org/health/wellness-and-prevention/depression-and-sleep-understand-

ing-the-connection.

Sage

© CQ Press 2023

CQ Researcher

Page 39 of 40 Aging and Mental Health

About the Author

Barbara Mantel is a freelance writer in New York City and the freelance community correspondent at the As-

sociation of Health Care Journalists. She has been a Kiplinger Fellow and has won several journalism awards,

including the National Press Club's Best Consumer Journalism Award and the Front Page Award. She holds

a B.A. in history and economics from the University of Virginia and an M.A. in economics from Northwestern

University. Her most recent CQ Researcher report was on obesity in America.

https://doi.org/10.4135/cqresrre20230324

Sage

© CQ Press 2023

CQ Researcher

Page 40 of 40 Aging and Mental Health