Senate Hearings: Suicide in Seniors

Concerns about senior suicide and the lack of geriatric mental health services took center stage at hearings in the Senate Special Committee on Aging on September 14. Geriatric psychiatrists reviewed unfavorable trends such as faltering numbers of medical school graduates going into primary care and already small numbers of geriatric psychiatrists getting even smaller.

Some of that pessimism had been on view at hearings the committee has held in the past. What was new, though, was a presentation by a Duke University psychiatrist on a primary care mental health program that he said held the opportunity for reaching many more seniors who may be racked by suicidal ideation. David Carl Steffens, MD, MHS, professor of psychiatry and medicine at Duke, presented findings related to IMPACT, which stands for "Improving Mood-Promoting Access to Collaborative Treatment" for late-life depression, sponsored chiefly by the John A. Hartford Foundation. The study, completed in 2002, focused mainly on treatment of serious depressive disorders in the elderly, specifically major depression and dysthymia.

But Steffens, who served as the study psychiatrist at the Duke General Internal Medicine site, said the data had recently been reviewed to see whether primary care intervention reduced suicidal ideation. Intervention subjects had significantly lower rates of suicidal ideation than did controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and, even after intervention resources were no longer available, at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%). There were no completed suicides in either group. These findings will soon be published in the Journal of the American Geriatrics Society.

Duke is one of the very few IMPACT study sites that has continued to use the primary care collaborative model funded by the Hartford Foundation; that is, use of a depression clinical specialist, who at Duke is a clinical nurse specialist. The problem is, Steffens recounted, that Duke administration has not found an acceptable way to cover his services (now that Hartford funding has ended). Medicare will cover the nurse's care, but not his supervisory role, even though there is a CPT code (99361) for a medical conference by a physician with an interdisciplinary team of health professionals.

Christopher Colenda, MD, the Jean and Thomas McMullin Dean of Medicine at Texas A&M University and president of the American Association for Geriatric Psychiatry, also noted the need for focusing more resources on primary care mental health services. He explained that rotations of medical residents are "inadequate nearly to the point of nonexistence for geriatric psychiatry."Colenda endorsed the Positive Aging Act (S. 1116), which was introduced in May 2005 by Senators Hillary Clinton (D, NY) and Susan Collins (R, Me). The bill would make available grants to states to provide screening and treatment for mental health disorders in seniors. In addition, it would authorize demonstration projects to reach out to seniors and would make much needed collaborative mental health services available in community settings where older adults reside and already receive services such as primary care clinics.

When she introduced the bill in May 2005, Clinton said: "Mental disorders do not have to be a part of the aging process, because we have effective treatments for these conditions. But in far too many instances, our seniors go undiagnosed and untreated because of the current divide in our country between health care and mental health care."

But while the bill was referred to the Senate Committee on Health, Education, Labor, and Pensions, of which Clinton is a member, it was never heard of again. Clinton's office failed to respond to a request for comment.