November 18, 2002
UCSD & County Mental Health to Collaborate on Intervention and Services Research for Older Adults with Psychotic Disorders
National Institute of Mental Health Funds UCSD
Advanced Center for Interventions and Services Research
Older adults suffering from psychotic disorders such as schizophrenia – a devastating, misunderstood and puzzling illness that dramatically alters an individual's thoughts, behavior and mood – are the focus of a unique collaborative program between the University of California, San Diego (UCSD) School of Medicine and the San Diego County Health and Human Services Agency's Adult and Older Adult Mental Health Services (AMHS).
Called the Center for Community-based Research in Older People with Psychoses, the program is funded by a $7.5 million, five-year grant to UCSD from the National Institute of Mental Health (NIMH). The primary community partner for the UCSD program is the AMHS, which has access to treatment and clinical trials. The goal is development of effective new therapies for middle-aged and elderly people with schizophrenia and other chronic psychotic disorders.
The program addresses an impending crisis with the growing number of middle age and elderly individuals with psychotic disorders, said the program's principal investigator Dilip Jeste, M.D., UCSD Estelle and Edgar Levi Chair in Aging, professor of psychiatry and neurosciences, and director of the Division of Geriatric Psychiatry. Jeste also heads the geriatric psychiatry program at the VA San Diego Healthcare System.
As the baby boomer generation ages, the number of people in the U.S. over age 65 is projected to double from about 35 million today to nearly 70 million by 2030. According to a landmark report in the September 1999 Archives of General Psychiatry, the number of elderly Americans who suffer from a mental illness is projected to grow to approximately 15 million by 2030, compared to about 4 million reported in 1970.
"Younger adults who have a serious mental illness, such as schizophrenia, currently have a significantly shorter life span than those without mental illness," Jeste said. "The average life span of these patients will increase, thanks to improved medication and other treatments. In addition, as people in the general population live longer, they will have a greater chance of developing certain psychiatric problems in later life."
Schizophrenia affects about 1 percent of the population. Middle-aged and older adults with schizophrenia – the focus of the UCSD/County program – often live alone, in homeless shelters, or on the street. Tormented by hallucinations, delusions and other forms of bizarre behavior, these individuals are usually unable to work or interact with society. These patients mainly include those who developed schizophrenia as adolescents or young adults and are now middle-aged or elderly, while a small proportion of the older patients have developed the illness for the first time in their later years (late-onset schizophrenia). One area of interest is the possibility of remission of schizophrenia in old age as illustrated in the recent Oscar-winning movie "A Beautiful Mind, " based on the true life story of John Nash, a Nobel laureate.
The NIMH award to UCSD is one of only three collaborative mental-health programs in the U.S. funded by the mental health agency to develop new treatment strategies for mental illness by combining the strength of university research with the breadth of community services. The other two programs are located at the Universities of Pennsylvania and Pittsburgh.
Called Advanced Centers for Interventions and Services Research by the NIMH, each of the three new programs has a unique focus. The San Diego program will address psychosis in older adults. The University of Pennsylvania center will study depression in the elderly while the center at the University of Pittsburgh will focus on mental disorders in children.
UCSD was chosen for the award based on its expertise in older-adult mental health, especially in the area of psychotic disorders. For the past 10 years, UCSD's Jeste has had the only NIMH-funded center specifically devoted to studying middle-aged and older adults with psychotic disorders.
Participating with UCSD in the new NIMH-funded program, San Diego County's AMHS hopes to improve patient intervention and treatment services by drawing upon UCSD's research expertise. In turn, the collaboration will allow UCSD to expand its investigations to include individuals who are living in assisted living centers, attending community programs, or are homeless.
"We see this as an excellent opportunity to use best-practice research to develop new interventions that are age-appropriate and culturally relevant," said Mark Refowitz, AMHS director. "We have so many unmet needs in this county. Unfortunately, we don't have the capacity to do research that determines the most effective, evidence-based practices. UCSD will be a wonderful partner in this endeavor."
"Our collaboration will allow the university to expand studies to a large number of patients in multi-cultural communities and various community settings. In addition, we will be able to include additional measurements of treatment effectiveness, such as quality of everyday life for these individuals," Jeste said.
He added that adults with schizophrenia and related psychotic disorders are much more likely to be in public healthcare systems than in private ones. This is even truer for older adults who are less likely to have family caregivers. Many of these patients are consumers of the AMHS (including county-run clinics such as the San Ysidro Mental Health Clinic, South Bay guidance, and the Maria Sardinas Center), with a sizeable proportion receiving treatment at the VA San Diego Healthcare System, which will also participate in the new program. In addition, numerous assisted care facilities, homeless shelters, and psychiatric centers are expected to participate in the program.
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For example, one area analyzed will be the use of emergency room, inpatient, crisis residential, day treatment, outpatient, and case management services by people from different ethnic groups, the two genders, and different age groups.
An example of a current UCSD research effort that will be expanded to include community settings is a study of medication adherence (compliance). People with schizophrenia frequently don't take their medications as prescribed, resulting in relapse, hospitalization and/or suicide. The study will focus on education as well as skills training designed to improve medication adherence.
University of California, San Diego
School of Medicine
UCSD's geriatric psychiatry research program, which started in 1986 with Jeste and one research fellow, now has more than 50 people including faculty, fellows and staff members. In 1992, the program became the first in the U.S. to be funded by the NIMH as a Clinical Research Center for Psychosis and Antipsychotics in Older Adults. When funding was renewed in 1996, the program expanded to include psychosocial interventions in this age group. Recently, a Bioethics Units has been added to conduct research on issues of decision-making capacity and informed consent in the older patients.
Other components of the geriatric psychiatry program are the VA Geriatric Psychiatry Clinic and the UCSD Senior Behavioral Health, an inpatient, outpatient, and community-based program that offers a combined psychiatric and medical approach for seniors age 65 and older. For example, the patients admitted to the UCSD inpatient unit are evaluated by a board-certified geriatric psychiatrist as well as assessed for any underlying medical or biochemical problems by a geriatric internist, a registered nurse, a neuropsychologist, a social worker and an occupational therapist.
The UCSD Division of Geriatric Psychiatry provides four federally funded training programs at local and/or national level. At the local level is a VA-funded clinical fellowship in geriatric psychiatry for post-residency psychiatrists as well as an NIMH-funded research fellowship for psychologists, psychiatrists and pharmacists. At the national level there is a highly successful 7-year-old NIMH-funded research training program called the Summer Research Institute in Geriatric Psychiatry, which provides mentorship to young clinical investigators from throughout the U.S. In addition, the newly funded Center will initiate a research training program called START-MH (Summer Training in Aging-related Research Topics – Mental Health) for undergraduates and medical students from across the country.
San Diego County Health and Human Services Agency,
Adult and Older Adult Mental Health Services
San Diego County Health and Human Services Agency – "Through partnership, and emphasizing prevention, assure a healthier community and access to needed services, while promoting self-reliance and personal responsibility."
Adult/Older Adult Mental Health Services – "To provide quality, cost-effective mental health treatment, care, and prevention services by dedicated and caring staff to people in the service population."
Older Adult System of Care – "Ensure quality, cost-effective culturally competent, age appropriate integrated mental health treatment, care, prevention and outreach services to older adults through collaboration with consumers, advocates, professionals and agencies working with the older adult community."
AMHS is responsible for providing treatment services to both persistently and acutely mentally disordered clients in a variety of settings, e.g. acute inpatient units, residential care settings, outpatient clinics, and partial day programs. Services are provided to children, adolescents, adults, and seniors and include evaluation and screening, diagnosis, treatment, referral, case management, continuing care, community services, advocacy, and services to the justice system. Emergency, acute and residential services are provided 24 hours, seven days a week to those whose mental, emotional and behavioral disorders require this level of attention. Services are provided through countywide inpatient and residential facilities, five regional clinics, approximately 60 contracted programs, and four locked long-term care programs. The County contracts with community hospitals for inpatient beds for persons eligible for Medi-Cal.
The Older Adult System of Care population includes individuals who due to mental disorders, have a reduction of functioning, and who are best served in the public specialty mental health system, including individuals with co-occurring disorders. These are individuals 60 years of age and older who have significant mental health symptoms that may interfere with their ability to remain independent and in the community. These individuals require integrated and comprehensive services.
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