SEPTEMBER 11, 2009, 10:00 AM

The New York Times

In Need of Psychiatric Care, and Resisting
By PAULA SPAN

Courtesy Dr. Cornelia CremensDr. Cornelia Cremens, center, with patients Phyllis and Robert Green.

The patient showed symptoms of severe depression. She hallucinated, seeing her dead father across her room. Her family was having trouble taking care of her.

Dr. Cornelia Cremens, the psychiatrist who saw the woman at Massachusetts General Hospital, suggested an evaluation at McLean Hospital — which as everyone in Boston (and anyone who read “Girl, Interrupted”) knows is a psychiatric facility.

“I could never go there,” the woman objected, appalled. “If anybody found out, I’d be stigmatized for the rest of my life.”

She was 98.

“People in general are reluctant to see a psychiatrist,” Dr. Cremens said, “but old people even more so.”

A generational divide yawns here. “Part of it comes from the culture that developed during the Depression: the strongest survived,” Dr. Cremens said. Her elderly patients think they should be able to fix themselves with determination and bootstraps, not with antidepressants.

“Nobody would tell you to walk on a broken leg, but if you’re depressed, people tell you to buck up,” Dr. Cremens said. “They think it’s better to hide it and not talk about it.”

The grown children of parents in need of psychiatric care — so much more accustomed to hearing about psychotherapy on talk shows, reading memoirs about 12-step programs, watching TV commercials starring sad little rocks that smile again thanks to Zoloft — often resort to subterfuge to get their parents simply to talk to someone like Dr. Cremens.

It is a pity we cannot be more matter of fact, because older people can benefit from psychiatry. Depression is not intrinsic to aging; it is as treatable in the older population, with talk therapy and drugs, as in the young. The befuddled state called delirium, related to physical illnesses in the aging, is also treatable. Dementia remains the heartbreaker. The available medications can slow its progress somewhat, in some patients, but there is still no way to prevent, stop or reverse it.

Still, older people suffering from mental disorders face a long list of unhappy consequences — poorer quality of life, reduced ability to live independently, higher rates of disability — that can often be avoided, or at least postponed.

A general psychiatrist can handle these disorders, but someone with geriatric training — a specialty not yet 20 years old — offers special advantages. Older patients present unique challenges. Their bodies metabolize drugs differently, so they usually need lower dosages. And they are likely to be taking an array of other remedies. Geriatric psychiatrists are particularly alert for potential drug interactions. Sometimes, Dr. Cremens focuses on taking patients off unnecessary drugs.

And, as with any specialist, “if you see older patients all the time, you recognize the subtleties of illness.”

The further pity, though, is that just as older people tend to avoid psychiatrists, psychiatrists do not seem to want to spend their careers with old people. Only 1,800 are board-certified in geriatric psychiatry, according to the American Association for Geriatric Psychiatry. That is about 4,000 to 5,000 fewer than needed, said Stephen J. Bartels, director of the Dartmouth Centers for Health and Aging, summarizing the the findings of a presidential commission. And geriatric psychiatrists are so unevenly distributed that whole states — like Idaho, South Dakota, Utah and Wyoming — have only one or two. (This map (PDF) shows how each state fares.) In fact, all kinds of health care professionals with geriatric training — geriatricians, pharmacists, psychologists, nurses — are in short supply, a problem certain to intensify.

An Institute of Medicine report issued last year examined some of the causes. The primary reason physicians avoid geriatrics, it said, was “financial disincentives,” a polite way of saying that when nearly all patients are on Medicare, income suffers. But the report also discussed “negative stereotypes” about working with older patients and how depressing it might seem. In reality, geriatric specialists generally enjoy their work, studies show. But fellowships to train geriatric psychiatrists go unfilled.

So older people with mental illness face a real bind. Their long-held prejudices make them reluctant to see psychiatrists. But if their families do manage, through one ploy or another, to induce them to seek treatment, in much of the country there are not enough specialists to help them.

Some of Dr. Cremens’s colleagues, she said, “go into child psychiatry where they feel they can have a real impact, change someone’s whole life.” But Dr. Cremens changes lives, too. And if those lives extend for only another 10 years, or 5, or 2, she has nonetheless reduced suffering and restored quality of life. Isn’t that what doctors are supposed to do?

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

http://newoldage.blogs.nytimes.com/2009/09/11/of-shrinks-shortages-and-subterfuge/