Integration of psychology, psychiatry, and medication in long-term care

Abstract

Use of long-term care (LTC) facilities has become a necessary alternative in the health armamentarium in all developed countries. In the United States, 24% die in nursing homes (Porock et al., 2005) . Although only 5% of individuals over age 65 are living in LTC facilities at any given point in time, nearly 40% will spend at least some portion of their lives there (U.S. Census Bureau, 2002 ). Annually almost 2 million adults are admitted to one of 16,800 nursing homes in the United States (Hyer & Ragan, 2002 ; Rhoades & Krauss, 1999) . The recent growth of assisted living facilities too - now estimated at over 36,000 facilities serving about one million residents (Stefanacci, 2005) - complements these nursing homes within the spectrum of LTC settings. Nursing homes themselves are now mini-medical facilities, functioning not as "homes" but as hospitals from the perspective of the residents (Bergman-Evans, 2004) . In this regard, LTC environments present residents with many challenges, including lack of privacy, confinement to an institutional schedule, and the knowledge that the LTC setting is likely to be an individual's final home. In this environment, the challenge of integrating mental health into the care of the aging within these varied LTC settings is enormously important. In fact, mental and medical pathologies often share a common expression and function. Physical changes, like those seen in Parkinson's disease, have definite medical etiologies, but frequently fall into the domain of mental health, given their neuropsychological properties and high incidence of comorbid depression (Dening & Bains, 2004). A majority of residents living in LTC facilities carry a least one psychiatric diagnosis. As many as 80% of nursing home residents will have dementia or another diagnosable psychiatric disorder (Hyer & Ragan, 2002 ; Rovner et al., 1990) . Furthermore, between 6 and 24% have a major depressive disorder diagnosis, 30% have minor depression or dysthymia, and as many as 35% manifest depressive symptoms. Minimum Data Set (MDS) reports that 14.6% of LTC residents have been diagnosed with anxiety disorder, though this rate may be deceptively low given limitations of assessment and in reporting anxiety symptoms within the MDS (Centers for Medicare and Medicaid Studies, 2004). Despite these high rates of psychiatric disorders, most residents are not under the care of a mental health clinician. Typically, these services are provided by independent psychiatric consultants who see specific residents on an as-needed, on-call basis (Bartels, Moak, & Dums, 2002) . In many cases medication alone is given. The Centers for Medicare and Medicaid Services (Boyle et al., 2004) report a 97% increase in antidepressant medications for all residents from 12.6% to 24.9%. Datto et al. (2002) suggest that 35% of nursing home residents receive antidepressant medication. The Practice of Mental Health in LTC Matters . Ormel, Van cen Brink, and Koeter (1995) indicated that evidence tells us that there are consequences to a lack of mental health input in these facilities, including (1) higher health care utilization and costs; (2) greater functional impairment; (3) increased utilization of staff time; (4) nonadherence to medical care; (5) increased mortality; and (6) reduced quality of life. Clinical common sense tells us that both dementia and depression result in increased time for staff, even after controlling for physical illness and disability (Fries et al., 1993) . Behavioral health care also makes a difference with medical procedures, as in hip-fracture, where residents receiving psychiatric services experienced fewer complications and were 9 times more likely to resume functioning at preoperative levels (Strain, Lyons, & Hammer, 1991). In this chapter we will address these issues. We discuss the medical model, as well as psychosocial models. We also provide a typology of residents in LTC for which the practice of psychology is applied. From here, we will address the psychiatric care of residents as viewed from the literature and clinical care in LTC. We then consider the practice of psychology in these settings, both assessment and treatment. Throughout, we argue that psychology, as a profession, makes a difference in LTC environments, and that integrated care is important, if not key, in the overall scheme of healthcare and life quality. © Springer Science + Business Media, LLC 2009.