​Kathryn Kietzman is a research scientist at the Center and lead author of a new study about the need for mental health services specifically for older adults. In this brief interview, she discusses generational differences in mental health needs, need among the homeless population, and workforce challenges to providing care.

Q: Your study focuses on older adults' mental health needs versus adults under 60 in the public health system. But you say even within the "elder" group there are generational differences in need?

​There is great diversity across the groups that represent the broad expanse of the 60+ population. Each generation has experienced a unique set of cultural, political, and economic factors that shape how they interact with each other and which may influence societal attitudes about mental illness. For instance, the baby boomer generation – those born between 1946 and 1964 – may be especially prone to substance use and addiction disorders which sometimes emerge in response to an unmet need for mental health services.

While some of the ''younger'' older adults in this category may see mental health services as a normal part of health care, some older baby boomers may experience significant stigma around help-seeking in general, a reluctance which may only be heightened when the help-seeking is specific to mental health issues.

Meanwhile, members of the ''oldest-old'' population, those who are 85+ years of age, are at greater risk than their younger cohorts of developing cognitive disorders like Alzheimer's. The onset of dementia and related disorders further complicates the treatment of serious mental illness – both from the standpoint of clinical care and from the standpoint of health care service delivery and financing.

Q: Mental health among the homeless population is often in the news, including the number of older homeless in need. But how do you find them to get them those services?

​Many of the homeless have mental health conditions and, unfortunately, older adults represent a sizeable and growing proportion of the homeless. Last year's count of homeless in Los Angeles revealed that 25 percent of the homeless population are 55 years of age and older. Within this group of older adults, more than one-third have serious mental illness and close to 20 percent have substance use disorders.

Sadly, older adults in general tend to be more "invisible'" members of our society, and homeless older adults may be even less visible. Among the 12,000 plus homeless older adults in Los Angeles County in 2017, only 2,200 (less than 20 percent) were considered "'sheltered'" homeless. Without an address, older homeless are even less likely to be able to apply for and access the supportive health and social care services that they likely need, especially as they are more likely to be living with multiple chronic conditions.

Indeed, their point of entry to health care, most typically the ER, may be the best place to identify and conduct outreach with homeless older adults. Mobile outreach services provide another productive strategy, often in the form of interdisciplinary professional teams that canvas places where the older homeless may congregate – at shelters, food banks, and soup kitchens. In addition, law enforcement and emergency medical personnel are among the most likely to regularly encounter the homeless of all ages. These first responders need special training to more effectively identify and screen older adults, to assess their needs, and get them to appropriate services.

Q: Your study focuses on the public health system lacking adequate mental health services for older adults, but does the private health system do a better job?

​Whether through public or private mental health care delivery systems, it is increasingly difficult to find and access the direct services of a psychiatrist, and those specializing in geriatrics are even fewer and farther in between! The longstanding and common denominator across the public and private systems of mental health care for older adults is workforce shortages and, more specifically, the lack of providers who are trained in geriatrics. The shortages in geriatric specialties traverses the full range of health provider types – including psychiatrists, primary care physicians, psychologists, and social workers – and dramatically affects the capacity of both public and private mental health delivery systems to identify and effectively respond to the unmet mental health needs of the older adult population.

Part of the problem may be linked to provider incentives in the form of Medicare reimbursement rates, which tend to be low, and which are used by many of the 65+ and/or disabled population to pay for mental health services. Another systemic issue is related to the workforce pipeline – the current shortages in the geriatric profession are certainly the product of the quality and intensiveness of training and curricula required of a broad range of health care professionals, much of which results in clinicians who are woefully unprepared to care for the aging population in general and even less prepared to care for those who are aging with mental illness.