Transforming Mental Health Care for Older Veterans in the Veterans Health Administration

Article excerpt

Older adults often lack familiarity with mental health symptoms and services and may hold negative beliefs about mental health care that can prevent them from seeking treatment.

Greater attention and new approaches to meeting the mental health needs of older Americans are critically needed. The nation's highly fragmented system of mental health care, in addition to barriers at policy and individual levels, has limited the utilization and provision of mental healthcare to older adults. Research has consistently shown that older adults with mental health problems infrequently utilize mental health services in both private and public mental health systems (Bogner et al., 2009; Karlin, Duffy, and Gleaves, 2008; Karlin and Norris, 2006). A recent national study of mental health service use by older and younger adults found that older adults were three times less likely than their younger counterparts to receive mental health treatment (Karlin, Duffy, and Gleaves, 2008). Even older adults with the greatest mental health needs were found to receive mental health care at low rates.

Older adults often lack familiarity with mental health symptoms and services and may hold negative beliefs about mental health care that can prevent them from seeking treatment. This is particularly the case with those in the "old-old" cohort whose knowledge and perceptions of mental illness and mental health treatment may be influenced by generational experiences. Modern understanding of mental illness and currently available treatments is quite different than conceptualizations of mental illness and treatments that existed during the earlier lives of today's oldest Americans.

Older adults who do seek treatment for mental health concerns often present to their primary care physician and rarely seek help in the specialty mental health sector. To further complicate matters, primary care physicians often under-detect mental health symptoms in older adults and may attribute mental health symptoms in older patients-feeling blue, experiencing decreased energy, activity, or interest-to normal aspects of aging. Limited Medicare coverage and other policy barriers have also significantly limited mental health care use by older adults (Karlin and Duffy, 2004; Karlin and Humphreys, 2007).

At the same time, research has consistently shown that mental health treatments, including specific evidence-based psychotherapies, are as effective with older adults as they are with younger adults. Specific adaptations to the pace and process of psychotherapy, including the use of multiple sensory modalities for presenting information and repetition and rehearsal of information, can help to maximize treatment gains with older individuals (Crowther and Zeiss, 2002; Karlin, in press; Molinari, 2003).

To effectively meet the mental health care needs of older adults, we must reshape and re-engineer how we provide mental health services. This involves moving outside the traditional highly fragmented and specialized mental health services toward a system of mental health care that is interdisciplinary, integrated, and evidence-based (Zeiss and Gallagher-Thompson, 2003). The Veterans Health Administration (VHA), the component of the Department of Veterans Affairs (VA) that coordinates healthcare delivery to veterans, is working to develop a mental health care system that embodies these fundamental elements, as part of a major effort to transform mental health care delivery in the VHA that began in 2005. This transformation process includes initiatives at the policy, system design, and program levels intended to improve mental health care access, utilization, and quality for veterans with mental illness, including specific initiatives targeting older veterans.

The VA Mental Health Care Delivery System

The VHA operates the largest and one of the most elaborate mental health care systems in the nation and perhaps the world. The VHA provides a broad array of mental health services across the full continuum of care, including inpatient, residential, and outpatient mental health settings at its medical centers and clinics. …