Depression, Social Isolation and the Urban Elderly  Conference on Geriatric Mental Health

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Presentation Outline. Mental Hygiene in New York CityKey Issues in Geriatric Mental HealthDepression Prevalence, Burden, and ComorbidityThe Epidemiology of Social IsolationOngoing InitiativesFuture Directions. Mental Hygiene in NYC. 1954: 1st NYC Mental Health Board1962: Deinstitutionalization begins1972: Alcoholism services added 1977: Mental Retardation services added1993: Early Intervention services added2002: NYC Departments of Health and Mental Hygiene merged.

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Depression, Social Isolation and the Urban Elderly Conference on Geriatric Mental Health

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1. Depression, Social Isolation and the Urban Elderly Conference on Geriatric Mental Health May 18, 2006 Lloyd I. Sederer, MD Executive Deputy Commissioner Mental Hygiene Services NYC Department of Health and Mental Hygiene

2. Presentation Outline Mental Hygiene in New York City Key Issues in Geriatric Mental Health Depression Prevalence, Burden, and Comorbidity The Epidemiology of Social Isolation Ongoing Initiatives Future Directions

3. Mental Hygiene in NYC 1954: 1st NYC Mental Health Board 1962: Deinstitutionalization begins 1972: Alcoholism services added 1977: Mental Retardation services added 1993: Early Intervention services added 2002: NYC Departments of Health and Mental Hygiene merged

4. Division of Mental Hygiene Planning, Purchasing and Providing quality control over mental hygiene services for New Yorkers of all ages by contracting with CBOs Population-based mental hygiene interventions: Depression Screening in Primary Care SBIRT, Buprenorphine and Naloxone – reducing overdose deaths in NYC Advocacy Public Education and Collaborating with NYC Stakeholders

5. Key Issues with Regard to Geriatric Mental Health Capacity: sheer projected growth of pop. over 65 (35 million nationwide nearly doubling by 2030) Increased co-morbidity of health and mental health Lack of specialized services Isolation of Seniors -Administration on Aging, 2002 In New York City, we are already challenged not only by increase in the number of seniors and the challenge of addressing the physical and mental health needs of baby boomers, but also by the racial and ethnic diversity of this population. In New York City, we are already challenged not only by increase in the number of seniors and the challenge of addressing the physical and mental health needs of baby boomers, but also by the racial and ethnic diversity of this population.

6. Older Adults and Mental Hygiene Approximately 366,000 adult aged 55 or older in NYC are affected by a psychiatric or a substance abuse disorder 1 in every 5 people 55 or older experiences a mental disorder – which is not a normal part of aging – and this figure is expected to double by 2030 In 2001, 124 adults in NYC age 55 or older committed suicide Citations: Prevalence and Cost Report 2003, DOHMH Surgeon General’s Report on Mental Health New York City Office of Vital Statistics Citations: Prevalence and Cost Report 2003, DOHMH Surgeon General’s Report on Mental Health New York City Office of Vital Statistics

7. Depression and Rates of Suicide in Older Adults Serious depression is the leading risk factor for suicide in older adults Among older patients who committed suicide, 20% visited their primary care physician on the same day as their suicide, 40% within the past week, and 70% within the past month

8. Prevalence of Depression In any given year, about 21 million American adults suffer a depressive episode, about 400,000 in NYC Lifetime Prevalence for a Major Depressive Disorder: 10-25% of women 5-12% of men Major Depression affects 10-13% of medical outpatients

9. Co-Morbidity Depression and Chronic Disease Depressive disorders are associated with increased prevalence of chronic diseases (e.g., asthma, diabetes, heart disease and stroke) Chronic disease worsens symptoms of depression Seven out of 10 office visits to a primary care doctor concern chronic diseases As a person ages, they are more likely to have health problems. For people with late onset mental disorders, the dual challenge of providing health and mental health services will require an increase in the integration of services. Primary care physicians and other health care providers need to be trained to detect depression and adequately treat it. Early screening and intervention may offer an opportunity to stem the rise of serious depression, the leading risk factor for suicide in older adults (Conwell, et.al, 1996). Often times, for most seniors, depression goes under-diagnosed and under-treated (Sederer, 2004) As a person ages, they are more likely to have health problems. For people with late onset mental disorders, the dual challenge of providing health and mental health services will require an increase in the integration of services. Primary care physicians and other health care providers need to be trained to detect depression and adequately treat it. Early screening and intervention may offer an opportunity to stem the rise of serious depression, the leading risk factor for suicide in older adults (Conwell, et.al, 1996). Often times, for most seniors, depression goes under-diagnosed and under-treated (Sederer, 2004)

10. Depressive Disorders Worsen Chronic Disease Increased somatic symptoms, eg, multiple pain complaints Greater functional disability Increased mortality Increased healthcare utilization and costs Poor self-management Decreased adherence to treatment regimens Greater drug interactions due to polypharmacy Some potential implications of depression coexisting or comorbid with a general medical illness include increased somatic symptoms, excess functional disability, increased morbidity/mortality, and increased healthcare utilization/costs. Patients’ self-care may be poor and their adherence to treatment regimens may decrease.15 Additionally, there is a greater potential for drug interactions in these patients due to polypharmacy.16Some potential implications of depression coexisting or comorbid with a general medical illness include increased somatic symptoms, excess functional disability, increased morbidity/mortality, and increased healthcare utilization/costs. Patients’ self-care may be poor and their adherence to treatment regimens may decrease.15 Additionally, there is a greater potential for drug interactions in these patients due to polypharmacy.16

11. Disparities and Untreated Depression in NYC (NYCHANES) Only 37% of New Yorkers with depression report receiving mental health treatment Of the NYers in treatment, only a quarter of African Americans and Hispanics (26% and 27% respectively compared with nearly half 49% of Whites) Untreated depression causes suffering, disability and most tragically, suicide Of those with Major Depressive Disorder (MDD), close to 50% report feelings of wanting to die, 33% consider suicide and 8.8% report a suicide attempt

12. Social Isolation There is a high rate of isolation among the elderly which creates a further obstacle to identifying and treating mental illness in this population. The loss of a social support network which occurs among he isolated elderly creates stress that increases the likelihood of developing mental health issues. Seniors with high scores on social isolation scales are more likely to report depression than seniors with low scores -Almeda County Study Social isolation is a complex problem that some find difficult to define. The factors that cause this isolation vary from person to person, as does its manifestation. Just because a senior lives alone or is naturally reclusive does not necessarily mean that he or she is lonely or without social supports. Instead, social isolation among seniors, commonly referred to as “senior isolation,” occurs when an older adult has such limited social ties that there are few places to turn for help or for social support when the need arises. A request from the United Neighborhood Houses was submitted to our epidemiology division to analyze the CHS data that we collected for risk factors for social isolation. -Almeda County Study Social isolation is a complex problem that some find difficult to define. The factors that cause this isolation vary from person to person, as does its manifestation. Just because a senior lives alone or is naturally reclusive does not necessarily mean that he or she is lonely or without social supports. Instead, social isolation among seniors, commonly referred to as “senior isolation,” occurs when an older adult has such limited social ties that there are few places to turn for help or for social support when the need arises. A request from the United Neighborhood Houses was submitted to our epidemiology division to analyze the CHS data that we collected for risk factors for social isolation.

13. Social Isolation and the Elderly Social Isolation in the elderly is associated with: Depression Re-hospitalization Delayed care-seeking Poor nutrition Premature mortality

14. Challenges of Engaging Socially Isolated Seniors Socially isolated seniors represent a hidden population that is difficult to identify. The size and geographic distribution of the population of socially isolated seniors in New York City is unknown. There are no population-based reports on the health characteristics of socially isolated seniors in New York City.

15. Community Partners Geriatric Mental Health Alliance Brookdale Center for the Aging United Neighborhood Houses: Report “Aging in the Shadows” described the problem of social isolation among seniors, the particular vulnerability of NYC seniors gave examples of program types and recommendations for change The report concludes that: NYC’s 1.3 million older adults are at greater risk of experiencing social isolation and its detrimental effects than their counterparts nationwide. Seniors in the City are more likely to be poor, disabled, and to live alone than their counterparts – all of which promote isolation The report concludes that: NYC’s 1.3 million older adults are at greater risk of experiencing social isolation and its detrimental effects than their counterparts nationwide. Seniors in the City are more likely to be poor, disabled, and to live alone than their counterparts – all of which promote isolation

16. DOHMH Epidemiology Report on Seniors at Risk for Social Isolation Produced by Dr. Tina McVeigh in our Division of Epidemiology In response to a request from UNH to further analyze our Community Health Survey Data with respect to social isolation risk factors Data used were not specifically collected for this purpose, but were extrapolated from existing data generated by our annual Community Health Survey. It is important to note that the factors in the paper by Dr. McVeigh have not been validated or evaluated in academic literature. This is a preliminary attempt to begin understanding the problem better and to inform further discussion and planning. It is important to note that the factors in the paper by Dr. McVeigh have not been validated or evaluated in academic literature. This is a preliminary attempt to begin understanding the problem better and to inform further discussion and planning.

17. Objective of the Analysis To identify and characterize seniors at risk for social isolation in New York City using existing data from the 2002 and 2003 New York City Community Health Survey.

18. Risk Factors Used in Analysis of Social Isolation Living alone Neither working nor belonging to a religious or community group Interrupted phone service for 24 hours or more in last year Meeting criteria for nonspecific psychological distress Being unable to work or experiencing at least 10 days of activity limitation in the past month attributable to health or mental health problems Feeling that one’s neighborhood is “quite unsafe” Having no friends or relatives to rely on for emotional support Data from the 2002 and 2003 New York City Community Health Surveys were combined and weighted to represent the New York City population. A risk index was derived based on the presence or absence of the following 7 risk factors Data from the 2002 and 2003 New York City Community Health Surveys were combined and weighted to represent the New York City population. A risk index was derived based on the presence or absence of the following 7 risk factors

19. Methods NYC Community Health Survey (CHS) Population-based Random digit-dialed telephone survey Approximately 10,000 respondents per year 1,601 respondents >=65 in 2002 1,618 respondents >=65 in 2003 CHS was not designed to assess social isolation.

20. Limitations of Self Reporting Our findings are limited by self report and proxy indicators of social isolation. We don’t know: Who we missed (false negatives) Who we incorrectly included (false positives)

21. Geographical Distribution Spatial analyses of these data identify a number of neighborhoods with high concentrations of seniors at risk for social isolation. These findings can be used to inform the development of targeted interventions to improve the longevity and quality of life of some of New York’s most fragile seniors.

22. Mapping of Results Total Number of New Yorkers Aged 65 and Older by Neighborhood Absolute Numbers of Seniors at Risk for Social Isolation Prevalence of Seniors at Risk for Social Isolation Prevalence of Nonspecific Psychological Distress among NYC Seniors

23. Total number of New Yorkers Age 65 and older by NeighborhoodTotal number of New Yorkers Age 65 and older by Neighborhood

26. You can that the South Bronx has both a high rate of seniors at risk for social isolation and seniors with nonspecific psychological distress (NPD), corroborating that the highest need lies here, where we have begun our initiatives. You can that the South Bronx has both a high rate of seniors at risk for social isolation and seniors with nonspecific psychological distress (NPD), corroborating that the highest need lies here, where we have begun our initiatives.

27. Distribution of Risk Factors for Social Isolation Among Seniors, by Nonspecific Psychological Distress (NPD) Status Nonspecific psychological distress is defined by having a 13 or higher on a scale that measures overall poor mental health This is measure does represent a clinical diagnosis of depression or other mental illness. There is a high correlation between the number of risk factors present for social isolation and the incidence of nonspecific psychological distress.Nonspecific psychological distress is defined by having a 13 or higher on a scale that measures overall poor mental health This is measure does represent a clinical diagnosis of depression or other mental illness. There is a high correlation between the number of risk factors present for social isolation and the incidence of nonspecific psychological distress.

28. Implications Using existing data from a population-based survey we were able to identify a subpopulation of seniors who appear to be at risk for social isolation. This group is more likely to be female, Hispanic, unmarried, poorly educated and poor.

29. Rates of Insurance and PCPs in Socially Isolated Seniors Despite poorer health, seniors at risk for social isolation had similar rates of health insurance and preventive care as seniors not at risk. They were, however, less likely to have a primary care provider and more likely to have deferred medical care because of cost.

30. What DOHMH Can Do Continuously improve measures for identifying and quantifying both seniors at risk for social isolation and individuals with mental health concerns Collaboration with DFTA, the Geriatric Mental Health Alliance, educational institutions, and partners in both primary care and mental health settings can lead to innovative solutions

31. Ongoing Public Mental Hygiene Solutions Increased Access to Buprenorphine Treatment for New Yorkers Addicted to Opioids including Prescription Painkillers Increased Depression Screening and Management in Primary Care

32. Buprenorphine Older adults can be at risk for addiction to pain killers as a result of surgery or chronic pain DOHMH has a five point plan to implement buprenorphine throughout NYC Buprenophine is a medication used to treat opioid addiction that can be prescribed by a physician in the privacy of an office visit and does not carry many of the obstacles or stigma of methadone maintenance

33. DOHMH Depression Initiative Screening seniors for depression in the Bronx Educate the public, reduce stigma: Public Education Campaign Subways, buses, check cashing sites Increase access to care Working with insurance providers and employers Implement depression screening and management in primary care practices throughout the City Outreach to Primary Care Providers including HHC, Voluntary Hospitals, FQHCs, and University Student Health Centers HHCs Electronic Health Record Depression detailers visiting 800 PCPs in City’s areas of highest need DOHMH Office of Care Management DOHMH provides training and technical assistance to PCP on how to incorporate depression screening and management into their practices. Emphasize evidence-base of detailing.DOHMH provides training and technical assistance to PCP on how to incorporate depression screening and management into their practices. Emphasize evidence-base of detailing.

35. Depression Screening for Seniors Pilot Program DOHMH, DFTA, MHA of NYC collaborated Funding for one full-time social worker to staff initiative Goal: screen seniors in senior centers and in their homes in the Bronx (CDs 1-6) Ultimate goal is to expand citywide Issues of mobility, seniors with transportation challenges, how do we bring the services to them? Homebound?Issues of mobility, seniors with transportation challenges, how do we bring the services to them? Homebound?

36. Why Screen and Manage Depression in Primary Care? Among older patients who committed suicide, 20% visited their primary care physician on the same day as their suicide, 40% within the past week, and 70% within the past month Patient preference and first line of “defense” Screening for depression in the primary care setting improves detection rates US Preventative Service Task Force (USPSTF) recommends screening adults for depression Only 50% of those referred to specialty mental health practitioners complete more than one visit

37. Depression in Primary Care Discuss our efforts to teach PCPs how to bill? Especially Medicaid, Medicare, Medigap, etc. Question: If billing for a mh services will get them paid less than billing for a health service, what is the incentive?Discuss our efforts to teach PCPs how to bill? Especially Medicaid, Medicare, Medigap, etc. Question: If billing for a mh services will get them paid less than billing for a health service, what is the incentive?

39. Depression Management Patient Education Foster provider-patient relationships, reduce stigma, enhance treatment adherence Treatment (Medication and/or psychotherapy) Combined treatment with antidepressants and psychotherapy is recommended as first line treatment for patients with severe major depressive disorder Depression is treatable in 65 to 75% of elderly patients Ongoing Monitoring Care management, follow-up PHQ9

40. Depression Campaign: Long term Goals Depression screening and management as a standard of care in all primary care practices Improve the number of people receiving treatment for depression Improve the quality of care and outcomes for individuals with depression

41. Need for Additional Linkages Communication of potential increased demand to local MH providers Continued efforts to increase capacity in mental health system Ongoing support for doctors and primary care settings with care managers Need to increase and improve workforce and its expertise in services to older adults Emphasis on role of care managers – telephonic support to individuals who are less mobile.Emphasis on role of care managers – telephonic support to individuals who are less mobile.

42. More Needs to Be Done Increased training for people entering the medical, mental health and service fields (Emphasis in our Hunter College Scholarship program for individuals who are focusing on geriatric services) Exploration of new models like integrated health/mental health teams (Diabetes/Depression Collaboratives as an example) Continued advocacy and support for additional resources

43. Conclusions Older individuals in urban areas are at high risk for both social isolation and depression and require new and creative solutions to reach and serve them.

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