Geriatric mental health: An overview

Journal of the American Psychiatric Nurses Association

S2 APNA Web site: www.apna.org Vol. 7, No. 6

One in eight Americans, or approximately 12.7%of the population, were 65 years of age or older

in 1999 (Administration on Aging [AoA], 2000). Ofthe 34.5 million elders, 20.2 million were womenand 14.3 million were men. The older adult popula-tion will continue to increase so that by the year2030, elders will comprise 20% of the population(AoA, 2001). Concurrently, the greatest growth willoccur in elderly minority populations. While thewhite population will increase by 81%, ethnic minor-ity elders will increase by 219%, including Hispanics(328%), Asian/Pacific Islanders (285%), AmericanIndians (147%), and African-Americans (131%) (AoA,2000).

The expanding elderly population will placeincreasing demands on health care services and create

greater demands for culturally competent mentalhealth care. The Surgeon General reports that 20% ofpersons 55 years and older experience mental disor-ders that are not a normal part of aging (U.S.Department of Health and Human Services [USDHHS],1999). Undiagnosed and untreated mental disorderssuch as depression can lead to increased disability,premature death, increased morbidity, increased riskof institutionalization, and a significant decrease in anelder’s quality of life. Mental health professionals mustbecome proactive and aggressive in addressing themental health and psychiatric disorders of older adultsto meet the goals for Healthy People 2010 to increasethe quality years of healthy life and eliminate healthdisparities (USDHHS, 2000).

OLDER ADULTS AND MENTAL HEALTH

Several key points derived from the SurgeonGeneral’s report on mental health are relevant to themental health of elders and the provision of services(USDHHS, 1999). First, normal aging is not character-ized by cognitive and mental disorders. In addition,there are important life tasks that remain as one ages,and continued intellectual, social, and physical activi-ties are important. The occurrence of stressful lifeevents does increase with age, but persistent bereave-ment and depression are not part of normal aging.However, it is anticipated that disability as a result ofmental illness will become a serious mental health

Diana Lynn Morris, RN, PhD, FAAN, is Associate Professor ofNursing at The Pennsylvania State University in UniversityPark, Pennsylvania, and Adjunct Associate Professor at CaseWestern Reserve University in Cleveland, Ohio.

Reprint requests: Diana Lynn Morris, RN, PhD, FAAN,College of Health and Human Development, School ofNursing, 307-C Health and Human Development East,University Park, PA 16802.

Copyright © 2001 by the American Psychiatric NursesAssociation.

1078-3903/2001/$35.00 + 0 66/0/120851

doi:10.1067/mpn.2001.120851

Geriatric Mental Health: An OverviewDiana Lynn Morris, RN, PhD, FAAN

The well-being of older adults is a major social and health concern in the United States. Of particularimport is the mental health of the expanding older adult population. Older adults often receive inade-quate or inappropriate mental health services. Provision of appropriate, efficacious care is a challengebecause of the complexity of determining the differential diagnosis of health problems in elders. Mentalhealth professionals require knowledge not only of the unique presentation of psychiatric disorders inolder adults but also of normal aging, diseases and disabilities of aging, and the cultural diversityfound between and among subgroups. For the purposes of this article, emphasis will be placed on geri-atric mental health, including issues and barriers that have affected the diagnosis and treatment ofmental health problems and psychiatric disorders in older adults. Areas of concern identified in therecent Surgeon General’s reports on older adult suicide and mental health will be presented. A caseexample will be used to illustrate key issues in geriatric mental health care. (J Am Psychiatr NursesAssoc [2001]. 7, S2-S7.)

Journal of the American Psychiatric Nurses Association Morris

December 2001 APNA Web site: www.apna.org S3

problem in persons 65 years of age and older(USDHHS, 1999).

In the face of the concern for increased disability,there is some good news about diagnosis and treatment.There are effective treatments for most mental disorders,particularly depression, which is a common disorder inolder adults. Data indicate that older adults benefit fromadvances in psychotherapy, medication, and other treat-ments (USDHHS, 1999, 2001). Further, treating olderadults with mental disorders results in additional bene-fits to the overall health status of elders. A critical linkin diagnosing and treating older adults’ mental disor-ders are primary care practitioners (USDHHS, 1999,2001), including advance practice psychiatric, geropsy-chiatric, and gerontology/geriatric nurses. However, it isimportant to note that barriers that affect access to men-tal health care still exist in the organization and financ-ing of mental health services for older adults (USDHHS,1999).

BARRIERS TO CAREStigma

The stigma of mental illness in society continues tobe a barrier to the provision of timely, efficaciousmental health services. Older adults may find it embar-rassing to admit to a mental health or emotional prob-lem. Older cohorts, in particular, come from a timewhen there were clear messages that psychiatric dis-orders were socially unmentionable, maybe evencriminal or equated with mental retardation. Mentaldisorders might also be viewed as a lack of moralcourage and integrity or a lack of faith. Family mem-bers, friends, acquaintances, and caregivers may holdsome of the same beliefs and attitudes about mentaldisorders and therefore do not assist an elder to accessservices. Thus older adults tend to seek care for allhealth problems, including overt and covert mentalhealth disorders, from their primary health careproviders.

Ageism

Access to appropriate care is further complicated bythe existence of ageism in a society that tends torevere a young, healthy ideal. Ageist attitudes on thepart of elders, families, and health professionals blockunderstanding of normal aging and mental disordersin older adults. If older persons or family membersrecognize the presence of depression, for example,they may not seek care because they believe thatwhen one is old, it is normal to be depressed or thereis nothing that can be done. Unfortunately, health pro-fessionals may hold similar attitudes and therefore notproperly diagnose, or if they do diagnose, not treat amental disorder such as depression.

Financial ResourcesFinancial barriers continue to exist across the con-

tinuum of care from primary care services throughlong-term care. Specific concerns have been raisedabout the provision of mental services to older adultsas it is affected by Medicare policy (Taube, Goldman,& Salkever, 1990) and the growth of managed care(Busch, 1997). The AoA has identified the need tocoordinate and strengthen federal, state, and privatefunding streams as a major challenge to access mentalhealth services for elders (USDHHS, 2001). Medicare(Title XVIII) was enacted in 1965 as an amendment tothe Social Security Act of 1935 (Kart, 1994; Kovner &Jonas, 1999) to provide older adults with financialaccess to health care. This financial and health policyaffects elders’ access to mental health services. Forexample, inpatient care in a free-standing psychiatrichospital is limited to 190 days lifetime but has few lim-its if care is provided in a general hospital or psychi-atric unit of a general hospital. A 50% copayment isrequired for outpatient psychotherapy, whereas thecopayment for most other outpatient services is only20%. However, partial hospitalization at a Medicare-certified and approved community-based mentalhealth center, hospital-based program, or free-standingprogram is an unlimited benefit with a 20% copayment(USDHHS, 1996). Medicare has limited long-term carebenefits for skilled care; thus most nursing home carefalls under Medicaid funding based on Title XIX of theSocial Security Act of 1965 (Kovner & Jonas, 1999).Each state has the option of determining minimumbenefits and fee structures, thus affecting the types ofcommunity treatment (Taube et al., 1990) and partici-pation in services by mental health professionals(USDHHS, 2001).

Workforce Issues

Workforce issues such as a shortage of geriatricmental health professionals and adequate educationand training of mental health professionals create andsustain barriers to care. Although some funding ofgeriatric mental health graduate education has beenprovided since the early 1980s, particularly by theNational Institute of Mental Health, funding isdescribed as inconsistent and recruitment difficult(Gatz & Finkel, 1995; USDHHS, 2001). Thus mentalhealth professionals often lack knowledge of theoriesof normal aging, geriatric disorders and disabilities,and the clinical presentation of and management ofpsychiatric disorders in older adults. At the same time,health professionals who specialize in gerontologyand geriatrics lack knowledge of psychiatric disordersin general and specific presentations found in an olderadult population. The result is often a lack of well-informed, collaborative services by health profession-

als prepared to address the complexity of providingmental health services that are timely and appropriateacross a variety of service delivery sites (e.g., primarycare, nursing homes, home-based, community-based).

Morris Journal of the American Psychiatric Nurses Association


Culturally Competent CareThe lack of culturally competent care is an addi-

tional barrier. Historically, racial and ethnic minoritygroups have been underserved in terms of mentalhealth services (Center for Mental Health Services,1998; Takeuchi & Uehara, 1996). Members of minori-ty groups have reported feeling fearful and uncom-fortable about using the mental health system(Scheffler & Miller, 1991; USDHHS, 1999). The lack ofattention to ethnicity and the effects of racial discrim-ination continue to affect the provision of mentalhealth care to older adults. Additional cultural factorsto consider when providing care to older adultsinclude one’s age cohort, sex, socioeconomic class,whether one is an immigrant and when immigrationoccurred, whether one’s experience is urban/subur-ban/rural, sexual orientation, and profession or workgroup values. In recent years models of cultural com-petence have been developed such as the CulturalCompetence Process Model (Campinha-Bacoate,1994), which has been applied to the care of psychi-atric populations. It is notable that in gerontology,there has been an emphasis on the health of minorityelders. This has led to an increasing body of knowl-edge regarding the mental health of minority elders(Baker, Espino, Robinson, & Stewart, 1993; Kim, 1995;Kuo & Kavanagh, 1994; Louie, 1999; Padgett, 1995;Torres, 1999). However, there are still gaps in inte-grating cultural knowledge and culturally competentskills into curricula, programming, and clinical prac-tice of health professionals.

MENTAL DISORDERS IN OLDER ADULTS

It is not the purpose of this article to address in detailthe variety of mental disorders experienced by olderadults. What will be presented is an overview to sensi-tize the reader to the range of disorders that may be pre-sented clinically. It is important to note that the onset ofdisorders in older adults varies widely (USDHHS, 2001).Some elders may have experienced severe, persistentmental disorders with episodic exacerbations. Othersmay have mental disorders late in life that can be trig-gered by losses (USDHHS, 2001) and comorbid physicalconditions (USDHHS, 2000).

Mood Disorders

The prevalence of mood disorders in persons 55 yearsof age and older is reported to be 4.4% (USDHHS,1999). The rate for major depression is 3.8%; unipolardepression, 3.7%: dysthymia, 1.6%; bipolar type I,0.2%; and bipolar type II, 0.1%.

Depression. The prevalence of depression in olderadults and related increased disability can have devas-tating effects on the quality of life of older adults. Both

Betty’s Story: An Exemplar

Betty’s son and daughter-in-law approached anurse after church one morning. Tim and Junewere very upset because the psychiatrist whohad examined their mother told them that Bettyhad dementia. The psychiatrist said that theprognosis was poor, and Betty would need tospend the rest of her life in a nursing home.Betty’s children asked if there was anything elsethat could be done. The nurse asked them somequestions about what had been going on withBetty. They reported that Betty, who was 68, hadbeen her usual active self until about 6 monthsago. Then she had quit attending church activi-ties regularly, was not calling or going to lunchwith friends, was staying in the house more andmore, resisted going to family gatherings, andjust was not taking care of herself. Betty was alsogetting more and more forgetful and anxious. Asa result of further questioning, the nurse wastold that a little over a year ago Betty’s husband,Matthew, was in a hospital about 100 miles fromhome. On one of the drives to visit him, Bettysuffered symptoms of a heart attack, and Junehad rushed her to a local hospital near the turn-pike. Everyone expected Matthew to havesurgery and return home. However, while Bettywas hospitalized for her heart attack, Matthewunexpectedly died in the hospital. Betty was notallowed to go to the hospital or the funeral. Thenurse suggested to Betty’s family that Betty maybe depressed but that a thorough assessmentwas needed. The nurse referred them to a geri-atric assessment unit in a nearby city. Betty wasdiagnosed with a major depression and treated.She had no signs of dementia. Betty is now 75and has never made it to the nursing home. Shecontinues to live in her own home and drivesher own car. Betty attends church and Sundayschool every Sunday, goes to lunch with friends,gets her hair done weekly, and drives 2 hours tovisit her grandchildren on a regular basis. This isthe result of a family who supported her andcontinued to ask questions of health profession-als and an accurate diagnosis and treatment bygeriatric and mental health specialists in a col-laborative practice.



the risk of institutionalization and the risk of suicideincrease. Approximately 8% to 20% of community-dwelling older adults experience depressive symp-toms, and 37% of elders in primary care settings havesymptoms (USDHHS, 1999). Rates of depression innursing homes are reported to range from 15% to 25%(USDHHS, 2000). Based on the Diagnostic andStatistical Manual of Mental Disorders, fourth edition,revised (American Psychiatric Association, 2000) crite-ria, some older adults may suffer from major depression(USDHHS, 1999). However, more frequently, particular-ly in the community-dwelling population, older adultsexperience minor depression (Alexopoulos, as cited inUSDHHS, 2001; Gallo & Lebowitz, 1999). Althoughthere is no standard for diagnosis of minor depression,such a diagnosis is generally made when there are fewersymptoms and less impairment than for major depres-sion (USDHHS, 1999). Older adults may continue to suf-fer from symptoms of depression and excessive func-tional disability because the depression is not diagnosedand treated or may be misdiagnosed as dementia (seesidebar). The result can be loss of independence, insti-tutionalization, and in some cases, suicide.

Suicide. The leading risk factor for suicide in olderadults is depression (Conwell et al., 1996). Twentypercent of suicide deaths occur in the older adult pop-ulation, with White men accounting for 84% of thesedeaths. The rate of suicide in persons aged 80 to 84years increased by 16% from 1980 to 1996 (USDHHS,1999). Seventy percent of older adults who commitsuicide have visited their primary care physician with-in the previous month (Cooper-Patrick, Crum, & Ford,1994; Courage, Godbey, Ingram, Schramm, & Hale,1993; USDHHS, 2001). Thus primary care physiciansand other providers such as advance practice nursesand home care nurses must become the front line foridentifying depression in older adults, including thoseat risk for suicide. Diagnosis should be followed byappropriate referral and aggressive treatment. Thefocus should be on the older person who is identifiedas the patient or client and other family members.Specifically, providers need to assess the mentalhealth of informal, family caregivers who are knownto be at risk for psychologic stress and distress relatedto caregiving.

Dementias and delirium. The symptoms ofdementia and delirium cause fear for older adults andtheir families. Fears about the loss of one’s mind, per-sonhood, and independence are the foundation ofelders’ concern. Alzheimer’s disease is the focus ofmost people’s fears and visions of being demented. Itis estimated that 8% to 15% of persons 65 years of ageand older have Alzheimer’s disease (Ritchie & Kildea,1995). The prevalence rate of dementias (all typesincluding Alzheimer’s and multi-infarct dementia)doubles every 5 years after 60 years of age (Jorm,

Korten, & Henderson, 1987; USDHHS, 1999). Theeffects on cognitive, social, and physical function aredevastating for the elder and the family. Mental healthprofessionals can be pivotal in the behavioral man-agement and treatment of symptoms such as delusionsand hallucinations. More importantly, mental healthprofessionals with a geropsychiatric perspective canassist geriatric colleagues in differential diagnosis. Thisis imperative for identifying delirium (acute confu-sional states) that is reversible with proper treatmentand diagnosis. If the proper diagnosis and identifica-tion of the etiologic basis of the delirium do not occur,there can be catastrophic consequence for the elder.Such a diagnosis requires knowledge of normal aging,diseases of aging, and the clinical presentations ofmental disorders in older adults.

Other Mental Disorders

Anxiety disorders. The prevalence of anxiety inpersons over age 55 years who live in the communityis 11.4%, but there is a paucity of research examiningthese disorders in older adults (USDHHS, 1999). Insome elderly populations, authors have reported thatgeneralized anxiety disorders occur at a rate of from1.2% to 17.3% higher than panic disorders and obses-sive compulsive disorders (Copeland et al., 1987).Himmelfarb and Murrell (1984) suggested that olderadults (17% of men and 21% of women) experiencesymptoms of anxiety that do not fit established diag-nostic criteria. However, it is thought that these feel-ings of worry and nervousness are important for men-tal health professionals to address (USDHHS, 1999). Inaddition, little is known about the late-life effects ofsevere trauma on the mental health of older cohortswho survived the holocaust, wars, and natural disas-ters. For future aging cohorts, it is proposed that thestudy of syndromes such as post-traumatic stress dis-order will be necessary as Vietnam era veterans age(USDHHS, 1999).

Schizophrenia. The prevalence of schizophrenia inthe older adult population is thought to be approxi-mately 0.6% (USDHHS, 1999). Although this is a smallnumber of the older adult population, the economicburden is high (Cuffle et al., 1996). Throughout theirlives, older adults who have carried the diagnosis ofschizophernia may have been victims of both the mis-diagnosis of physical illness and less aggressive pre-ventive health care for nonpsychiatric diagnoses. As aresult, older adults with schizophrenia may suffer thesequelae of poor health care earlier in life. In addi-tion, these elders experience the same chronic illness-es and disabilities suffered by other older adults. Thus,any comorbid conditions and disabilities warrant con-sideration in the management and treatment of theirpsychiatric illness. Jeste and colleagues (1997) report-

ed that persons with late-onset and early-onset schiz-ophrenia are similar in clinical presentation, treatmentresponse, and course. However, persons with late-onset schizophrenia are more likely to be women,have paranoia as a dominant feature, have less impair-ment in specific cognitive function, and require lowerdoses of medication (USDHHS, 1999).

Alcohol and Substance Use Disorders

In current older adult cohorts, substance problemsare related to alcohol use and the use of over-the-counter and prescription drugs. The abuse of illicitdrugs is not thought to be a common problem in theolder adult population. However, as younger genera-tions move into old age, the pattern of illicit drug usemay change and become a major concern.

Alcohol use. Heavy drinking occurs at a rate of 3%to 9% in older adults (Liberto, Oslin, & Ruskin, 1992).Some older adults who are heavy drinkers may havesurvived into old age with an early-onset addiction toalcohol. However, some elders are late-onset drinkerswho may have begun to have a drinking problem inlate middle age and begin to exhibit health problemsrelated to alcohol abuse as they move into older adult-hood. It is important to understand that older adultswho have used alcohol in the past without abuse oraddiction may experience problems with alcohol con-sumption as changes occur in their bodies as a resultof normal aging (e.g., decreased liver function,changes in body composition).

Prescription and over-the-counter drug use. Acommon substance use disorder for older adults is themisuse of prescribed and over-the-counter medication.Misuse takes several forms including underuse,overuse, and erratic use of medication with the rareinstance of dependence (USDHHS, 1999). The misusemay be a result of the older adults’ difficulties in read-ing, understanding, and following directions for use ofspecific medication. The situation is often furthercomplicated by management regimens that includemultiple pharmacologic agents. The difficulty may restwith the health professional who is responsible formanagement of the treatment regimen. This is oftenthe result of a lack of knowledge of the effect of nor-mal aging changes on pharmacodynamics, the man-agement of psychopharmacologic agents in elders, orboth.

GEROPSYCHIATRIC NURSING: CHALLENGE ANDOPPORTUNITY

Providing care to older adults is challenging in thatit requires expertise in gerontology and geriatrics andpsychiatric mental health and specifically knowledgeabout the presentation and management of mental dis-

orders in elderly populations. This is necessary ifhealth professionals are to have the knowledge andskills needed for differential diagnosis and integratedmanagement of mental health care for older adults.The opportunity is there for advance practice psychi-atric nurses and clinical staff nurses to enhance thequality of care for older adult clients.

There are several routes that can be taken to achievethis goal. One approach, which has been supportedby the National Institute of Mental Health in the past,is to recruit psychiatric and gerontology nurses intograduate programs in geropsychiatric nursing. Inessence, these nurses have a dual specialty, takingcore courses in psychiatric mental health nursing andgerontologic nursing and special courses in geriatricmental health. Another route is for psychiatric mentalhealth specialists to take postgraduate certificatecourses in gerontologic nursing or geriatric nurse prac-titioner programs, adding a geriatric mental healthcourse. Gerontology clinical specialists and geriatricnurse practitioners would focus on postgraduate workin psychiatric mental health nursing with a specialtycourse in geriatric mental health. A final option wouldbe to encourage collaborative practice models whereadvance practice gerontology and geriatric nursespartner with advance practice psychiatric and geropsy-chiatric nurses.

REFERENCESAdministration on Aging. (2000). A profile of older Americans: 2000.

Washington, DC: U.S. Department of Health and HumanServices.

American Psychiatric Association. (2000). Diagnostic and statistical man-ual of mental disorders (4th ed., rev.). Washington, DC: Author.

Baker, I. M., Espino, D.V., Robinson, B. H., & Stewart, B. (1993).Assessing depressive symptoms in African American andMexican American elders. Clinical Gerontologist, 14(1), 15-29.

Busch, S. (1997). Carving-out mental health benefits to Medicaidbeneficiaries: A shift to managed care. Administration and Policy inMental Health, 24, 301-321.

Campinha-Bacoate, J. (1994). Cultural competence in psychiatricmental health nursing: A conceptual model. Nursing Clinics ofNorth America, 29, 1-8.

Center for Mental Health Services (CMHS). (1998). Cultural competencestandards in managed care mental health services for fourunderserved/under-represented racial/ethnic groups. Rockville, MD:Author.

Conwell, Y., Duberstein, P. R., Cox, C., Hermann, J. H., Forbes, N. T.,& Caine, E. D. (1996). Relationships of age and axis I diagnosesin victims of completed suicide: A psychological autopsy study.American Journal of Psychiatry, 153, 1001-1008.

Cooper-Patrick, L., Crum, R. M., & Ford, D. E. (1994). Identifyingsuicidal ideation in general practice. Journal of the American MedicalAssociation, 272, 1757-1762.

Copeland, J. R., Gurland, B. J., Dewey, M. E., Kellcher, M. J., Smith,A. M., & Davidson, I. A. (1987). Is there more dementia, depres-sion and neurosis in New York? A comparative study of theelderly in New York and London. British Journal of Psychiatry, 151,466-473.

Morris Journal of the American Psychiatric Nurses Association




Courage, M. M., Godbey, K. L., Ingram, D. A., Schramm, L. L., &Hale, W. E. (1993). Suicide in the elderly: Staying in control.Journal of Psychosocial Nursing & Mental Health Services, 31(7), 26-31.

Cuffle, B. J., Cyrus, P. A., Halpain, M., Pratt, C., Turke, H., &Patterson, T. L. (1996). Treatment costs and use of communitymental health services for schizophrenia by age cohorts.American Journal of Psychiatry, 153, 870-876.

Gallo, J. J., & Lebowitz, B. D. (1999). The epidemiology of commonlate-life mental disorders in the community: Themes for a newcentury. Psychiatric Services, 50, 1158-1166.

Gatz, M., & Finkel, S. (1995). Education and training of mentalhealth service providers. In M. Gatz (Ed.) Emerging issues in mentalhealth and aging (pp. 282-302). Washington, DC: AmericanPsychological Association.

Himmelfarb, S., & Murrell, S. A. (1984). The prevalence and corre-lates of anxiety symptoms in older adults. Journal of Psychology,116, 159-167.

Jeste, D. V., Symonds, L. L., Harris, M. J., Paulsen, J. S., Palmer, B. W.,& Heaton, R. K. (1997). Nondementia nonpraecox dementia prae-cox? Late-onset schizophrenia. American Journal of Geriatric Psychiatry,5, 302-317.

Jorm, A. F., Korten, A. E., & Henderson, A. S. (1987). The prevalenceof dementia: A quantitative integration of the literature. ActaPsychiatrica Scandinavica, 76, 465-479.

Kart, C. S. (1994). The realities of aging: An introduction to gerontology (4th

ed.). Boston: Allyn and Bacon.Kim, M. T. (1995). Cultural influences on depression in Korean

Americans. Journal of Psychosocial Nursing & Mental Health Services,33(2), 13-18.

Kovner, A. R., & Jonas, S. (Eds.). (1999). Jones and Kovner’s health deliv-ery in the United States (6th ed.). New York: Springer Publishing.

Kuo, C. L., & Kavanagh, K. H. (1994). Chinese perspectives on cul-ture and mental health. Issues in Mental Health, 15, 551-567.

Liberto, J. G., Oslin, D. W., & Ruskin, P. E. (1992). Alcoholism inolder persons: A review of the literature. Hospital and CommunityPsychiatry, 43, 975-984.

Louie, K. B. (1999). Status of mental health needs of Asian elderly.In M.L. Wykle & A. B. Ford (Eds.). Serving minority elders in the 21st

century (pp. 148-159). New York: Springer Publishing.Padgett, D. K. (Ed.). (1995). Handbook of ethnicity, aging, and mental

health. Westport, CT: Greenwood Press.Ritchie, K., & Kildea, D. (1995). Is senile dementia “age-related” or

“aging-related”? Evidence from meta-analysis of dementia preva-lence in the oldest old. Lancet, 346, 931-934.

Scheffler, R. M., & Miller, A. B. (1991). Differences in mental healthservice utilization among ethnic subpopulations. InternationalJournal of Law and Psychiatry, 14, 363-376.

Takeuchi, D. T., & Uehara, E. S. (1996). Ethnic minority mental healthservices: Current research and future conceptual dimensions. InB. L. Levin & J. Petrila (Eds.), Mental health services: A public healthperspective (pp. 63-80). New York: Oxford University Press.

Taube, C. A., Goldman, H. H., & Salkever, D. (1990). Medicaid cov-erage for mental illness: Balancing access and costs. HealthAffairs, 9(1), 5-18.

Torres, S. (1999). Barriers to mental-health-care access faced byHispanic elders. In M. L. Wykle & A.B. Ford (Eds.), Serving minorityelders in the 21st century (pp. 200-218). New York: Springer Publishing.

U.S. Department of Health and Human Services, Health CareFinancing Administration (HCFA). (1996). Medicare and you: 2000.Washington, DC: Author.

U.S. Department of Health and Human Services (USDHHS). (1999).Mental health: A report of the Surgeon General. Rockville, MD: U.S.Department of Health and Human Services, Substance Abuseand Mental Health Services Administration, Center for MentalHealth Services, National Institutes of Health, National Instituteof Mental Health.

U.S. Department of Health and Human Services (USDHHS). (2000).Healthy people 2010. Rockville, MD: Author.

U.S. Department of Health and Human Services (USDHHS). (2001).Older adults and mental health: Issues and opportunities. Rockville, MD:U.S. Department of Health and Human Services, Administrationon Aging.

Documents

Geriatric mental health: An overview