June 6, 2000
"We often get discouraged that the most vulnerable people are the least likely to benefit from care — that's clearly not the case here"
In the case of older adults with psychiatric problems, a four-year Johns Hopkins study has shown that a program combining observations by janitors, building managers and others who frequently see elderly people and the skills of a highly accessible psychiatric nurse can significantly increase seniors' mental health and stability.
The research, reported in today's Journal of the American Medical Association, highlights the first large-scale, low-cost, medically successful approach to the dilemma that elderly people on their own are far less likely to be diagnosed or treated for mental illness than younger adults, according to psychiatrist Peter Rabins, M.D., who directed the study.
Elderly people are less likely to get treated for mental illness for a host of reasons, Rabins says: "Their generation's reluctant to admit to mental health problems; they may have insufficient insurance or even a simple lack of transport to the doctor's office. No single solution tackles all the reasons," he adds, "but this new program, based on quickly recognizing mental problems and improving access to care shows large populations can be helped affordably."
In a test of the PATCH program — for Psychogeriatric Assessment and Treatment in City Housing — involving 945 senior residents of six public housing sites in Baltimore, residents in the three test sites scored 17 percent higher in a test of general mental health than those in the three sites without it. The PATCH group also scored 32 percent lower on a standard test measuring depression.
"We often get discouraged that the most vulnerable people are the least likely to benefit from care — that's clearly not the case here," says Rabins.
Though still experimental, PATCH has proved so successful that it now operates in every public housing site in Baltimore, Rabins says.
In the PATCH system, a psychiatric nurse trains housing staff — custodians, maintenance workers, managers — to recognize changes in a resident's behavior that may clearly signal a psychiatric problem. In hour-long sessions, staff learn about normal and abnormal aging, mood disorders, schizophrenia, substance abuse, dementia and death/dying issues. They become "case finders" who weekly refer at-risk residents to the nurse.
The PATCH nurse then approaches residents, asking to administer a short series of mental diagnostic tests. A mini-medical exam including vital signs and medical/psychological histories is part of the work-up.
Finally, the nurse and a team psychiatrist confer about the best treatment approach with the resident, arranging in-home or off-site care. They back off when a system's in place to provide needed resources, Rabins says.
"A key feature of this study," he adds, "is that it depends heavily on nurses who have both mental health and medical training. Having them provide care where people live seems to overcome the stigma of mental illness for elderly residents as well as solve transportation difficulties and the complicated interaction between medical and emotional problems that often prevents people from getting help."
The nearly 1,000 residents in the study received psychiatric screening before researchers divided them into sociologically similar PATCH and non-PATCH groups. Neither the nurse nor housing staff knew which residents had previously tested at-risk for psychiatric problems. At the study's end, the researchers re-surveyed and interviewed all the residents, again measuring psychiatric symptoms.
"We picked this particular population," Rabins says, "both because of ease of access and because we knew from earlier studies that people in public housing tend to be in greater need of psychiatric help."
The PATCH project involved an unusually tight collaboration between an academic center and state and city agencies — in this case Hopkins, the Maryland Department of Health and Mental Hygiene and the Housing Authority of Baltimore City. One city housing administrator, for example, was on the PATCH program's board of directors. "The teamwork surely contributed to success," says Rabins.
The study was funded by the National Institute of Mental Health and the Maryland Department of Health and Mental Hygiene. Other researchers were Betty Black, Ph.D., Beatrice Robbins, R.N., Rebecca Rye, R.N., of Hopkins, Robert Roca and Marsden McGuire of the Sheppard and Enoch Pratt Hospital in Baltimore, and Larry Brant with the National Institute on Aging in Baltimore.