National Alliance on Mental Illness
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The Depression Boom: As U.S. Population Ages, Mental Illness Rises
One Doctor’s Focus to Treat Older Adults
By Courtney Reyers, NAMI Director of Publishing
With Baby Boomers reaching late adulthood, the chance for developing depression, anxiety and other mental illnesses could rise. Depression affects more than 6.5 million of the 35 million Americans aged 65 years or older. One psychiatrist in particular, Dr. Dilip Jeste, addresses the needs of older populations when it comes to mental illness. He specializes in late-onset schizophrenia, depression in older populations and psychosis. Currently, he is the Distinguished Professor of Psychiatry and Neurosciences, Estelle and Edgar Levi Chair in Aging, and Director of the Sam and Rose Stein Institute for Research on Aging, at the University of California, San Diego School of Medicine. He is also the president of the American Psychiatric Association. Dr. Jeste is the first Asian American to ever be elected president of the APA, and is the first psychiatrist from India to be elected to the Institute of Medicine at the National Academy of Sciences. He is a renowned lecturer and accomplished author. NAMI was fortunate enough to recently speak with Dr. Jeste about his work. If you’d like to hear Dr. Jeste speak, plan on attending NAMI’s National Convention in June.
NAMI: You focus on geriatric psychiatry. Can you speak to the difference in mental illness in older populations vs. the general population?
Jeste: Over the next 25 years, with the aging of the baby boomers, we will witness the largest increase in the numbers of people over age 65 in the history of mankind. What is less well-known is the fact that the numbers of older people with mental illness will actually increase at a disproportionately faster rate than those in the general population. This will be, in part, because of higher incidence of depression, anxiety disorders and substance use disorders among people born after the World War II than in those born earlier. Other reasons include decreasing social stigma, resulting in a larger proportion of older people being diagnosed with and treated for mental illness and an increase in the average life span of people with serious mental illness, which is currently 20 years shorter than that in the general population.
Just as children are not small adults, elderly people are not merely older adults. They have unique health care needs. The most common neuropsychiatric disorder in older people is dementia, especially Alzheimer’s disease. While major depression is less common, milder forms of depression are far more common than in younger adults. Also, because of age-related changes in the functioning of liver, kidneys and brain, older people can only tolerate lower doses of most medications and are at a greater risk of developing a number of side effects. They also have special needs for psychosocial treatments (e.g., they are less likely to be living with their families). Additionally, they tend to have major physical illnesses and disabilities, have visual and hearing impairments, and have even less access to health care than younger adults. As a result, fewer than half of older Americans with mental illness receive the needed mental health services. They face the dual stigma of mental illness and aging. Finally, there is a severe shortage of workforce trained to provide the necessary mental and physical health care for the growing numbers of older adults.
Can you tell us your thoughts on “wisdom?” What does it mean to you, and how would you define it?
Jeste: I have developed increasing interest in the area of successful aging: what makes older people do well, feel happy and contribute to society at a high level. This led me to do research on wisdom and to study whether wisdom increases with aging. Wisdom, a unique attribute rich in history dating back to the dawn of civilization, is a newcomer to the world of empirical research. For centuries, wisdom was the sole province of religion and philosophy, but I believe it is a real entity with biological roots.
Defining wisdom is rather subjective, though there are many similarities in definitions across time and cultures. Components of wisdom that are commonly agreed on include: thoughtful decision-making, empathy, compassion or altruism, emotional stability, self-understanding, decisiveness and tolerance for divergent values.
Research suggests that there may be a neurobiological basis for wisdom's components. Several specific brain regions appear to be involved in different components of wisdom. Neurobiology of wisdom probably involves an optimal balance between more primitive brain regions (the limbic system) and the newest ones (pre-frontal cortex.)
Understanding the neurobiology of wisdom may have considerable clinical significance, for example, in studying and eventually treating disorders such as antisocial personality disorder and certain types of dementia such as the fronto-temporal dementia. In addition, age-associated wisdom may help to overcome the negative effects of diseases and stressors that are common in late life and lead to improved mental health and psychosocial functioning.
What are some challenges you see in your work in terms of older populations and mental illness?
Jeste: The existing infrastructure and financing of health care, pool of mental health care providers with adequate geriatric training and mental health care delivery systems are extremely inadequate to meet the challenges posed by the expected increase in the numbers of older adults with mental illness. A national crisis in geriatric mental health care is emerging. Today there are only about 1,800 board-certified geriatric psychiatrists in the U.S.—one for every 23,000 older Americans. That ratio is estimated to diminish to one geriatric psychiatrist for every 27,000 individuals 65 and older by 2030. Yet, little is being done to address this challenge. Deliberate and coordinated action is urgently warranted.
A basic problem is pervasive ageism. The aging of the population is often dubbed as the “silver tsunami.” Older people are seen as a burden on the society, especially in terms of rising costs of Social Security and Medicare. Yet our study suggests that there is a growing number of old adults who can be productive and contribute to the society in many ways. Successfully aging seniors can, in fact, be a great resource for younger generations. I consider this “the positive psychiatry of aging,” which will be the future of our field.