[Senate Hearing 109-779]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-779
 
       A GENERATION AT RISK: BREAKING THE CYCLE OF SENIOR SUICIDE

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           SEPTEMBER 14, 2006

                               __________

                           Serial No. 109-32

         Printed for the use of the Special Committee on Aging




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                       SPECIAL COMMITTEE ON AGING

                     GORDON SMITH, Oregon, Chairman
RICHARD SHELBY, Alabama              HERB KOHL, Wisconsin
SUSAN COLLINS, Maine                 JAMES M. JEFFORDS, Vermont
JAMES M. TALENT, Missouri            RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
MEL MARTINEZ, Florida                EVAN BAYH, Indiana
LARRY E. CRAIG, Idaho                THOMAS R. CARPER, Delaware
RICK SANTORUM, Pennsylvania          BILL NELSON, Florida
CONRAD BURNS, Montana                HILLARY RODHAM CLINTON, New York
LAMAR ALEXANDER, Tennessee           KEN SALAZAR, Colorado
JIM DEMINT, South Carolina
                    Catherine Finley, Staff Director
               Julie Cohen, Ranking Member Staff Director


                                  (ii)



                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Gordon Smith........................     1
Opening Statement of Senator Herb Kohl...........................     3

                                Panel I

David Carl Steffens, M.D., M.H.S., professor of Psychiatry and 
  Medicine, and head, Division of Geriatric Psychiatry, Duke 
  University Medical Center, Durham, NC..........................     4

                                Panel II

Christopher C. Colenda, M.D., M.P.H., The Jean and Thomas 
  McMullin Dean of Medicine, Texas A&M University, College 
  Station, Texas, and president, American Association for 
  Geriatric Psychiatry...........................................    44
Melvin Kohn, M.D., M.P.H., State Epidemiologist, Public Health 
  Division, Oregon Department of Human Services, Salem, OR.......    54
Art Walaszek, M.D., assistant professor of Psychiatry and 
  director of Psychiatry Residency Training, University of 
  Wisconsin School of Medicine and Public Health, Madison, WI....    59
David Shern, president and chief executive officer, National 
  Mental Health Association, Alexandria, VA......................    65

                                APPENDIX

Prepared Statement of Senator Ken Salazar........................    77

                                 (iii)




       A GENERATION AT RISK: BREAKING THE CYCLE OF SENIOR SUICIDE

                              ----------                      



                      THURSDAY, SEPTEMBER 14, 2006

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room SD-562, Dirksen Senate Office Building, Hon. Gordon H. 
Smith (chairman of the committee) presiding.
    Present: Senators Smith and Kohl.

     OPENING STATEMENT OF SENATOR GORDON H. SMITH, CHAIRMAN

    The Chairman. Good morning, ladies and gentlemen, and thank 
you for your attendance here at this Committee hearing of the 
Senate Special Committee on Aging. This is a topic that tugs at 
the heart strings, but is very important. We have entitled it 
``A Generation at Risk: Breaking the Cycle of Senior Suicide.''
    Today's hearing focuses on an issue that is of particular 
importance to me, that of mental illness and suicide 
prevention. Since suffering a family tragedy, I have felt a 
personal call to action to shed light on the struggle of 
millions of Americans coping with a mental illness. As my wife 
and I became involved in the issue of suicide prevention, we 
were overwhelmed by personal stories of those battling mental 
illness. Sharon and I now share in a fraternity of sorrow with 
those who have lost loved ones to this killer.
    Though it is not a common perception, seniors are at a much 
higher risk for suicide than those of other age groups. While 
those over the age of 65 account for only 13 percent of the 
U.S. population, they account for 20 percent of the Nation's 
suicides. The problem only worsens with age. Compared with 
suicide rates of younger men, suicide rates of men over the age 
of 85 are two to three times higher. Statistics such as these 
are alarming, and that is why this hearing is so important. It 
is critical that we raise public awareness of this issue and 
discuss ways to reduce these startling and tragic statistics.
    Suicide across the age spectrum is becoming an epidemic. 
There is work being done at the Federal level, but we still 
have a very long way to go. The Aging Committee has served as a 
forum to examine the needs of seniors, all kinds of needs, and 
to highlight better ways to serve them. This Committee was the 
first to bring this important issue to light with a hearing in 
1996, and I hope today's work will serve as a call to action.
    It is a sad irony that as medical technology evolves to 
extend lives, seniors are choosing to end theirs. Retirement 
should be a time to relax, travel, and spend time with 
grandchildren. Unfortunately, seniors often are exposed to 
circumstances that can lead to depression, such as social 
isolation, physical illness, and the death of loved ones. I 
think it is very important that we understand that depression 
is neither a weakness nor a normal part of aging. Depression at 
any age is a very real disease. No one should suffer in 
silence.
    What many fail to realize is that suicide is entirely 
preventable. The senior population, however, presents unique 
challenges. As a generation, seniors are less likely to talk 
about their symptoms or to seek help. More than any age group, 
seniors suffer from the stigma associated with mental illness, 
and many are unaware of or are too ashamed to pursue treatment 
options.
    Fortunately, there are ways to help seniors in dealing with 
these issues. Studies show that 77 percent of seniors saw their 
primary care physician within one year of their suicide and 58 
percent saw their primary care physician within one month. 
Clearly, the primary care setting is the critical component of 
suicide prevention and intervention.
    This hearing will examine the quality of mental health care 
given to seniors and will look for ways to improve upon the 
ability of primary care doctors to recognize the signs of 
depression among their senior patients. Today, we will hear the 
results of a ground-breaking study that demonstrates the 
effectiveness of serving the mental health needs of seniors in 
a primary care setting.
    As one of Oregon's Senators, I am very pleased that my home 
State has a particularly innovative model of suicide 
prevention. It has this, I suppose, in spite of and maybe 
because of the assisted suicide law in our State. It is the 
only State to implement a comprehensive suicide prevention plan 
for seniors. I am looking forward to learning more about their 
efforts today and those of several other experts in the field 
of suicide prevention. It is a pleasure to have all of you here 
and I truly appreciate your sharing your experiences with us 
today.
    There is a vote scheduled at 11, so we are going to try to 
be expeditious and give sufficient time to each of our 
witnesses. What you have prepared to share is important to us 
and will help us better understand how we in the Federal 
Government can help you to prevent suicide among seniors and 
among all people.
    With that, I turn to my colleague, Senator Kohl, for his 
opening remarks.

             OPENING STATEMENT OF SENATOR HERB KOHL

    Senator Kohl. Thank you, Mr. Chairman, for holding this 
important hearing. We all admire your steadfast leadership and 
commitment to helping our Nation's families prevent tragic 
cases of suicide. We look forward to today's discussion of how 
to make sure seniors who suffer from depression find the help 
that they need.
    Our Nation is slowly making progress in removing the stigma 
of mental illness, but today too many seniors still fall prey 
to depression. Some are ashamed, some believe it is just a fact 
of life in old age, and some don't know where to turn for help. 
In fact, a survey of seniors found that only 38 percent believe 
depression is a health problem and more than half responded 
that it was just a normal part of aging. But depression, as we 
all know, is not a normal part of aging and it is treatable. 
Yet, too often seniors are left untreated and suicidal.
    Seniors make up 13 percent of our population, but account 
for close to 20 percent of all suicides. In fact, 75 percent of 
older people who commit suicide have seen their primary care 
doctor within the last month of their lives, as our Chairman 
has pointed out, and our health care system has failed them. So 
we must do more.
    Doctors must be trained to recognize and respond when their 
senior patients are depressed. We also need more geriatric 
specialists to manage the care of older patients who face 
multiple health problems. Today, there are only 5 geriatricians 
and 1.4 geriatric psychiatrists for every 10,000 seniors. We 
have pushed for funding for the Federal geriatrician training 
program to address these shortages and we hope that that 
program will be restored.
    As the Nation prepares for the retirement wave of 77 
million baby-boomers, we need to rethink the way mental health 
care is provided to seniors. Today, we will hear from two 
panels of distinguished experts who will explain the problem of 
senior suicide and suggest creative models to prevent it. I am 
very pleased that Dr. Art Walaszek, a leader in this field in 
Wisconsin, is here to share his experience and his work.
    Again, we thank you, Senator Smith, for organizing this 
hearing.
    The Chairman. Thank you very much, Senator Kohl.
    Our first panel consists of Dr. David Steffens. He is a 
professor of psychiatry and medicine, and head of the Division 
of Geriatric Psychiatry at Duke University Medical Center. Dr. 
Steffens is also a chief investigator on the IMPACT study and 
will discuss publicly the findings of this ground-breaking 
study today.
    Thank you for coming, Dr. Steffens.

 STATEMENT OF DAVID CARL STEFFENS, M.D., M.H.S., PROFESSOR OF 
   PSYCHIATRY AND MEDICINE, AND HEAD, DIVISION OF GERIATRIC 
     PSYCHIATRY, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC

    Dr. Steffens. Senator Smith and Senator Kohl, I want to 
thank you for inviting me to give testimony about suicide, an 
important public health matter that affects Americans across 
the age spectrum, but as we have heard, has a disproportionate 
effect on older Americans.
    As a geriatric psychiatrist, when I look at the CDC 
statistics, the take-home message for me is the alarming 
suicide rate for white men 85 and over. The large majority of 
these victims used a firearm to kill themselves. I want to 
shift my testimony, however, in a positive direction and talk 
about solutions. Both the NIH and private foundations are 
helping to develop an evidence base for prevention of suicide 
in older adults. One example is the NIMH-funded PROSPECT trial. 
Completed in 2003, PROSPECT showed a positive result when a 
collaborative team involving a depression care manager and 
physicians working in primary care practices came together to 
treat depression. Intervention participants showed significant 
reductions in suicidal ideation at 4 and 8 months when compared 
with the treatment-as-usual group.
    I will now focus on the IMPACT study. In 1998, the John A. 
Hartford Foundation took the lead in supporting the study 
``Improving Mood-Promoting Access to Collaborative Treatment,'' 
or IMPACT. Dr. Jurgen Unutzer, now at the University of 
Washington, is the IMPACT principal investigator.
    IMPACT focused on treatment of major depression and 
dysthymia in the elderly. Patients were drawn from 18 primary 
care clinics, from 8 health care organizations in 5 States, and 
were randomized to working with depression clinical specialists 
in the primary care clinic versus receiving usual care for 
depression in primary care. Depression clinical specialists 
were trained to use an anti-depressant medication algorithm and 
they also received special training for delivering problem-
solving therapy, a six- to eight-session brief, structured 
psychotherapy for depression. We found a powerful effect for 
the intervention in treating depression.
    More recently, we analyzed the IMPACT data to determine the 
effect of the intervention on reducing suicidal ideation 
specifically. At baseline, just to give you an idea, 15 percent 
of intervention patients and 13 percent of treatment-as-usual 
patients reported thoughts of suicide. At 6 months and 12 
months, intervention subjects had significantly lower rates of 
suicidal ideation than those in the comparison group. 
Remarkably, after the 1-year intervention was over, we still 
found an effect at 18 months and 24 months. There were no 
completed suicides in the study. Our findings will be published 
in the Journal of the American Geriatric Society.
    I served as an IMPACT study psychiatrist at the Duke 
general internal medicine site. In that capacity, I met each 
week with the two depression clinical specialists to review the 
new and returning cases they had seen that week. We made 
specific written recommendations to the primary care physician, 
who had to sign off on them before they could be implemented.
    Thus, the main thrust of our collaborative work was two-
fold: first, keeping the primary care physician in charge of 
the final treatment decision and, second, striving to keep the 
care of the depressed patient in the primary care setting. 
Occasionally, I would need to see patients largely to evaluate 
treatment refractory patients or to assess suicide risk.
    I am happy to report to you that at the Duke site, this 
collaborative care model did not end when the IMPACT study 
ended. As you might imagine, the primary care physicians in the 
practice came to value highly their work with the depression 
clinical specialists. As the IMPACT study wound down, we moved 
to implement the model as a clinical service in primary care. 
Now, I work with a master's-level clinical nurse specialist who 
functions as a care manager in primary care. We have also 
expanded the patient population to include adults ages 18 and 
above. In the past 4 years, the care manager has seen 478 
referred patients in over 3,000 visits, including 171 older 
adults and 129 older adults with depression.
    The Hartford Foundation is currently supporting efforts 
aimed at implementation of the IMPACT model, including care 
manager training seminars and development of educational 
materials to help clinic managers incorporate the model into 
primary care practices. In sum, IMPACT provides a good model 
for tackling the problem for suicide in the elderly. It focuses 
on management of depression, the condition most commonly 
associated with suicide.
    Its other key feature, provision of care in the primary 
care setting, is appealing for several reasons. For one, older 
adults may perceive stigma of mental illness more than other 
age groups and thus may be more reluctant to go to a separate 
psychiatric clinic. Second, most older adults have primary care 
doctor, but they may not have access to a psychiatrist, let 
alone a geriatric psychiatrist. Third, the IMPACT study has 
shown that most depressions can be treated in the primary care 
setting.
    It has been both personally and professionally satisfying 
to me to be able to implement in the clinical setting an 
intervention that I know works in the research setting. I look 
forward to hearing your thoughts and questions about suicide 
and suicide prevention, about the IMPACT study, and about ways 
we might be able to make changes in our health care system that 
will make a real difference in addressing the alarming suicide 
rates experienced by our greatest generation of older 
Americans.
    Thank you.
    The Chairman. Thank you, Doctor. My question really comes 
out of a conversation I had recently with one of my colleagues, 
who happens to be a baby doc deliverer, Senator Coburn, of 
Oklahoma, who indicated to me that fully half of his practice 
was psychiatrist counseling. I don't speak for him, but I 
believe he represented to me a view that he felt mental health 
teaching parity is vitally needed in our medical schools.
    When I talk to medical school folks, they say, oh, no, 
everything is fine, we cover that. Yet, I am not sure I have 
talked to a doctor who says to me--they are not psychiatrists, 
but they say, you know, I got a little bit, but I really didn't 
know it sufficiently to treat it in a primary care setting. I 
am wondering if you can comment on the notion of mental health 
teaching parity.
    Dr. Steffens. Thank you, Senator. We certainly have 
experienced that at Duke University and I think our school is 
not alone in this. As technology advances, there is a 
temptation to become quite enamored of it in medical school 
teaching, to be at the cutting edge, and there is only so much 
time that is left for teaching. We find particularly when 
teaching psychiatry and managing mental illness that the formal 
amount of time that is set aside for psychiatry rotations is 
lessened. That tends to, I think, give the impression that 
these illnesses are less important.
    Unfortunately, it is a sad reality in many teaching 
institutions that other specialties and an emphasis on 
technology may be more prominent, and therefore you get not 
only short shrift in terms of the time spent, but the overall 
message it sends to our future workforce of doctors about the 
importance of mental illness is worrisome to me as well.
    The Chairman. So you think some emphasis perhaps from 
Congress on mental health care teaching----
    Dr. Steffens. Yes, sir.
    The Chairman. You think we ought to do that?
    Dr. Steffens. Yes, sir. Any incentives that can be provided 
in terms of mental health teaching, involvement more of faculty 
with expertise and, in fact, teaching about models like the 
IMPACT model about the importance of collaborative care are 
important.
    The Chairman. You would agree, I suppose, given your 
background, that if a person has physical health but not mental 
health, they don't have health.
    Dr. Steffens. It is a matter of quality of life and I 
certainly agree with that, Senator.
    The Chairman. As you consider the primary care industry 
system, how would you grade it in our country right now in 
terms of mental health?
    Dr. Steffens. In terms of mental health, it is hard because 
just thinking about the----
    The Chairman. When you look at your model and how effective 
it is, how many have those models?
    Dr. Steffens. It is something that is sorely needed. It is 
certainly a vast minority of practices that have the ability 
right now to incorporate this model. So anything that you all 
can do to help with that----
    The Chairman. You are a teacher. You grade papers, don't 
you? How would you grade primary care as to mental health? 
Would you give them a D?
    Dr. Steffens. I want to be more encouraging to them, so I 
will give them a C----
    The Chairman. OK, they got a C.
    Dr. Steffens [continuing]. In part because I think there is 
a recognition of the importance of depression. It is now a 
matter of what tools can we do, given how busy primary care 
physicians are, to help them then effectively treat depression 
in the primary care setting.
    The Chairman. Would you agree with me that Tom Cruise is a 
great actor?
    Dr. Steffens. He is a fantastic actor, yes, sir.
    The Chairman. What kind of a mental health physician do you 
think he is?
    Dr. Steffens. I think that----
    The Chairman. Let me ask you a better question.
    Dr. Steffens. Yes, yes. [Laughter.]
    Is post-partum depression real? Is it a legitimate medical 
condition?
    Yes, sir.
    The Chairman. I agree. Is bipolar condition a real 
condition?
    Dr. Steffens. Yes, sir.
    The Chairman. How about schizophrenia?
    Dr. Steffens. Yes, sir.
    The Chairman. They are identifiable medical conditions?
    Dr. Steffens. They are.
    The Chairman. You know what they are and there are 
treatments for those that actually work?
    Dr. Steffens. Very effective treatments, yes, sir.
    The Chairman. I wanted that on the record.
    Dr. Steffens. Yes.
    The Chairman. I wonder, as you consider the primary care 
system, what can we in Congress do to help improve it? What 
specific things would you----
    Dr. Steffens. Well, I know that, for example, Senator Kohl 
has mentioned the reauthorization of the training for 
geriatricians under Title VII. We are hopeful that that is 
something in terms of just the pipeline and access aspect. 
There are other things, including making the Centers for 
Medicare and Medicaid Services--suggesting that they include a 
suicide assessment for individuals with mental illness as a 
quality indicator for care.
    There are some issues around the donut hole in Medicare 
Part D in terms of we do have effective treatments particularly 
on the pharmacology side, but they do have an expense and 
sometimes people will choose to drop their depression treatment 
as opposed to their diabetes or other types of treatments, 
unfortunately, at their own peril. So those are some aspects.
    The Chairman. We actually don't have pharmacology parity, 
do we, in Federal law as relates to mental health?
    Dr. Steffens. Right, and we don't have mental health parity 
more broadly, and it seems to me that this is one area, given 
that our focus is primary care, where perhaps a CPT code could 
be developed for this type of collaborative model that would, 
in fact, be reimbursed more at the 80-percent level than at 
just the 50-percent level. That may make it more attractive to 
primary care business managers to think about incorporating 
this if they see that they can get sufficient reimbursement 
such that it definitely adds the quality. But will it be either 
a revenue-neutral or a minor revenue-losing or a slightly 
revenue-producing enterprise?
    The Chairman. But if mental health care is legitimate, 
shouldn't it be equal to physical?
    Dr. Steffens. Absolutely.
    The Chairman. OK, that is my point. Probably the most 
important thing we could do in a short-term, tangible way would 
be medicine parity for mental health.
    Dr. Steffens. Absolutely.
    The Chairman. Anything else you can identify? We have got 
teaching parity, pharmacological parity. Anything else?
    Dr. Steffens. I think we have covered most of the bases.
    The Chairman. Senator Kohl.
    Senator Kohl. Dr. Steffens, as you well know, primary care 
doctors who see patients with multiple chronic disease often 
don't have the time to also do a full assessment of the 
patient's mental state. In your program, they are on the front 
lines and very involved. Do you think that most doctors might 
be willing to take on this challenge?
    Dr. Steffens. I think that there will be a willingness, 
Senator, but I think that the truth is that right now the 
incentives are for spending very little time, in general, 
seeing patients both in terms of the reimbursement that one 
gets from third-party payers, but even clinic managers 
sometimes will give bonuses if people can keep their volume up. 
So, certainly, there are very few incentives.
    So I think that primary care physicians now understand the 
importance of treating depression, but they have, I think, one 
of the toughest jobs out there in terms of trying to balance 
all of the patient's problems, treating the patient as a whole 
and trying to incorporate time to deal with depression.
    This is one model, Senator, that I think would be very 
helpful to the primary care doc because it keeps physicians not 
only in the loop, but at least the way we have implemented it, 
they have to sign off on the recommendations that the care 
manager makes after consultation with me. So this is something 
that I think they would find very appealing because it is not, 
well, we will just refer it out and maybe I will get a note 
about it every once in a while. That is not the way that this 
works. This is something that intimately involves the primary 
care physician and I think that they would be open to it.
    Senator Kohl. Well, data from your program show that 
patients had fewer suicidal thoughts after 6 months of therapy 
and medication. If this is a successful model, then how should 
we encourage more doctors and health care systems to use it?
    Dr. Steffens. I think that, one, the financial incentives, 
changes to the system that we have talked about in terms of 
mental health parity; improving access that they have to 
geriatricians by increasing the pool of geriatricians; making 
people aware through meetings like this about resources that 
are available, for example, through the American Association 
for Geriatric Psychiatry, through the John A. Hartford 
Foundation that sponsored the original study.
    They are now moving into what is called IMPACT II, which is 
actually the dissemination of information and production of 
tool kits for primary care physicians and managers to describe 
how they can best incorporate this model.
    Senator Kohl. Primary care physicians who deal with chronic 
diseases in the elderly are not trained or qualified in many 
cases to deal with the mental aspect of it. To the extent that 
this is true or, as you pointed out, they don't have the time 
to pursue this, how do we get beyond this? If we don't get 
beyond this, it seems to me, we are not going to deal with the 
problem.
    Dr. Steffens. I think that certainly now there is a 
recognition. If you look at the journals in primary care, as 
well as the conferences that are sponsored, depression and 
mental illness are now incorporated. So I think the message is 
trying to get out there that mental disorders are just like 
other physical conditions and should be part of what primary 
care physicians can deal with.
    The sad truth is that most depressions can be managed in 
the primary care setting if appropriate time is allotted. So I 
think again that the willingness is there. It is a matter of 
managing time, of providing the incentives, for example, 
through changes in Medicare, providing certain CPT codes that 
would actually allow for them to spend the time or to work in 
the collaborative model as well.
    Senator Kohl. Thank you. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Doctor, thank you very much. We appreciate your 
contribution this morning. It has been very helpful.
    Dr. Steffens. Thank you, sir.
    The Chairman. We honor your work and we just need to get it 
out on a larger basis.
    Dr. Steffens. Thank you, sir.
    [The prepared statement of Dr. Steffens follows:]
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    The Chairman. Our second panel will consist of Dr. Richard 
Colenda. He serves as the dean of the Texas A&M Health Sciences 
Center in the College of Medicine and is the current president 
of the Association of Geriatric Psychiatry. Dr. Colenda will 
provide an overview of current mental health curricula in 
medical academia and discuss specific efforts needed to improve 
mental health services for seniors.
    He will be followed by my constituent, Dr. Mel Kohn, who is 
State epidemiologist and administrator for the Office of 
Disease Prevention and Epidemiology in the Oregon Department of 
Human Services. Dr. Kohn will discuss Oregon's innovative 
efforts to combat elder suicide on a statewide level.
    Senator Kohl has already introduced his constituent, Art 
Walaszek, who is a geriatric psychiatrist and the residency 
training director at the University of Wisconsin School of 
Medicine and Public Health. As a clinician, Dr. Walaszek will 
present his personal experience treating seniors with mental 
health illnesses and discuss solutions to some of the barriers 
confronting seniors as they seek help.
    Finally, we will hear from Dr. David Shern, who is the 
president and CEO of the National Association of Mental Health. 
Dr. Shern brings with him a long history of advocacy and 
expertise in the area of mental health. His testimony will 
focus on current programs in place to reduce the rate of 
suicide in seniors.
    Thanks to all of you for coming. Dr. Colenda, take it away.

STATEMENT OF CHRISTOPHER C. COLENDA, M.D., M.P.H., THE JEAN AND 
THOMAS McMULLIN DEAN OF MEDICINE, TEXAS A&M UNIVERSITY, COLLEGE 
    STATION, TEXAS, AND PRESIDENT, AMERICAN ASSOCIATION FOR 
                      GERIATRIC PSYCHIATRY

    Dr. Colenda. Good morning, sir. Mr. Chairman and members of 
the Committee, I am Chris Colenda. I am dean of Medicine at the 
Texas A&M Health Science Center, and also president of the 
American Association for Geriatric Psychiatry. My testimony 
this morning reflects both my work in academic medicine, which 
involves the education and preparation of the next generations 
of physicians, as well as my own clinical and research practice 
which is in geriatric psychiatry.
    As heard earlier, the toll of mental illness among older 
adults, those age 65 and older, is stunning. Suicide is the 
horrible outcome of late-life mental illness, especially those 
with depression, and older men have the highest rates of 
suicide in the Nation. One-third of older adults who die from 
suicide have seen their primary care physician in the week 
before their deaths, and 70 percent have seen their physicians 
within the last month of life.
    Mr. Chairman, depression is not a normal part of aging. 
Depression is an illness that can be successfully treated at 
any age that it strikes. The symptoms that a practitioner, 
either a generalist or a mental health specialist, needs to 
recognize often vary according to age and culture, but 
depression is real and treatable.
    How can we improve the quality of health care delivered to 
the elderly and thus prevent or ameliorate the tragic outcomes 
for seniors such as suicide and reduced quality of life? As you 
heard earlier, we know a lot and we know what works, but I 
offer three main strategies from the perspective of a dean of a 
medical school.
    The first is to improve the content of geriatric curriculum 
and core competencies throughout the continuum of medical 
education from medical school, through residency, through 
continuing medical education. This education should include 
late-life psychiatric disorders.
    We must also have sufficient numbers of geriatric mental 
health specialists to lead the field in research, education and 
treatment. We must move to integrated longitudinal systems of 
care that bring together multiple health care disciplines--
primary care, mental health care and rehabilitation--with the 
goal of promoting functional independence and quality of life.
    Academic medicine must increase its commitment to these 
aspects of professional training, but what makes this issue so 
striking is that in the hyper-competitive environment of 
academic medicine, we are not getting the necessary resources 
to make sure that these programs are in place. Competition for 
time and resources in training is a huge factor in both mental 
health and primary care specialties.
    Mental health is complicated and stigmatized, and so is old 
age. The two together lead to a collective set of negative 
attitudes that lead to significant disincentives both in terms 
of financial reimbursement for services at medical schools as 
well as the intangibles derived from the long-held and deeply 
ingrained dual stigma of mental illness and fragile old age.
    In my written testimony, I have suggested a number of 
specific steps that the Federal Government should take to begin 
to address this problem. First, we need a solid study 
commissioned by the Institute of Medicine to determine the 
geriatric medicine and geriatric mental health and geriatric 
psychiatry workforce needs to serve the next generation of 
patients coming through the pipeline.
    We need to summarize the best practices for programs 
delivering mental health services such as what you heard 
earlier today in primary care and community settings. We need 
to incorporate tool sets to provide best educational and 
training practices to enhance geriatric core competencies and 
promote inter-professional education.
    We need to fund the geriatric health professions education 
programs such as those that were under Title VII. We need 
geriatric loan forgiveness programs to encourage practitioners 
to specialize in geriatrics and the requirements for inclusion 
of older adults in clinical trials. We need the NIMH to 
dedicate more research time and more research resources for 
mental health and psychiatric illnesses in older adults.
    Finally, sir, the financing of our health care systems, 
especially for the elderly and especially those with late-life 
mental disorders, requires a fresh look. Today's system of 
reimbursement for primary care, preventive and mental health 
services does not foster integration and compassionate 
longitudinal care. It fragments care either through volume or 
through technology. Our current financing system rewards 
technology, and in so doing provides strong incentives for 
young physicians to pursue careers where the money is, as 
opposed to the rewarding careers of primary care, psychiatry, 
geriatric medicine and geriatric psychiatry.
    Without fundamental financial reform, we will not recruit 
the best and the brightest into the field. In my lifetime, 
without fundamental financial reform and because of the 
demographic imperatives of the baby-boom generation, the health 
care system will simply collapse. Academic medicine has a steep 
hill to climb in developing and implementing adequate training 
for practitioners who care for the elderly. The scope and the 
size of the task are going to increase sharply over the next 
two decades.
    Mr. Chairman, academic medicine and the field of geriatric 
psychiatry and geriatric medicine welcome this Committee's 
active concern about this issue and we look forward to working 
with you to help increase the public's awareness and to combine 
public and private resources to help find remedies for this 
issue.
    [The prepared statement of Dr. Colenda follows:]
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    The Chairman. Thank you. Those are excellent suggestions.
    I think in the interest of time, before the vote comes up, 
we will ask questions after, Senator Kohl.
    Dr. Kohn.

 STATEMENT OF MELVIN KOHN, M.D., M.P.H., STATE EPIDEMIOLOGIST, 
 PUBLIC HEALTH DIVISION, OREGON DEPARTMENT OF HUMAN SERVICES, 
                           SALEM, OR

    Dr. Kohn. Mr. Chairman, Senator Kohl, thank you very much 
for inviting me to speak with you today. For the record, I am 
Dr. Mel Kohn. I am the State Epidemiologist in the Public 
Health Division at the Oregon Department of Human Services. In 
that capacity, I oversee a wide variety of public health 
programs, including communicable disease control, chronic 
disease control, and injury prevention, and it is in the latter 
capacity that I have gotten involved with the suicide 
prevention work that we have been doing.
    Today is actually my 47th birthday, and thank you; it is 
really a very nice birthday present to be able to come and 
speak about something that I feel very passionately about and I 
think is really, really important.
    The Chairman. I could actually think of better places to be 
on your birthday, but we are glad you are here. [Laughter.]
    Dr. Kohn. Senator Smith, I also really want to thank you 
and your wife for the courageous leadership that you have 
provided for suicide prevention efforts.
    When I talk about suicide, one of the first places I like 
to start is with how big a problem this is. I think most people 
are surprised to learn that every year in the United States we 
have roughly 20,000 homicides that occur. We all agree that is 
a huge problem, but we have over 30,000 suicides that occur 
every year.
    In my State of Oregon, almost three-quarters of our violent 
deaths are due to suicide. In 2003, almost 600 Oregonians died 
from suicide, and that is more than the number of Oregonians 
who died in motor vehicle crashes.
    The Chairman. Give me that number again.
    Dr. Kohn. Almost 600 Oregonians in 2003.
    As folks have already alluded to, the rate of suicide 
increases dramatically with age. In recent years, in Oregon, 
the rate of suicide among those age 65 was three times the rate 
among those age 10 to 24. I should say this is not unique to 
Oregon. For all States, the age group with the highest suicide 
rate is older adults.
    Now, because of this huge toll that suicide is taking, our 
injury prevention program, together with other partners from 
our human services agency working in mental health and in 
senior services, convened a statewide planning process to 
create an older adult suicide prevention plan. I did bring a 
few copies with me and I will share those with you afterwards. 
They are also available on our website.
    The Chairman. When did you produce that?
    Dr. Kohn. This was launched, I believe, last year. It is 
fairly recent.
    Through a grant from the Centers for Disease Control, we 
convened a multidisciplinary work group that reviewed available 
data and research literature and interviewed experts in the 
field, as well as service providers and older adults. With this 
information, we developed a prevention framework. We then held 
six community forums around the State to gather public input on 
the proposed framework, which also served to raise awareness 
about what a huge problem this is. Based on what we learned, we 
wrote our plan.
    For this process, we were very fortunate that we had 
funding from the Centers for Disease Control for the National 
Violent Death Reporting System. That data source allowed us to 
learn many more details about the circumstances of older adult 
suicide in Oregon that were useful for crafting our prevention 
approach.
    For example, almost 50 percent of the men and 60 percent of 
the women above age 65 who died by suicide were reported to 
have a depressed mood before death--perhaps not surprising. 
However, only a small proportion of those depressed people, 14 
percent of the men and 29 percent of the women, were under 
treatment for their depression, suggesting that screening and 
treatment for depression might have saved many of these lives.
    Ninety-three percent of the decedents had a chronic illness 
and over a third of them had visited a physician in the last 30 
days of their life, suggesting, as has already been discussed, 
that primary care office visits are a very feasible opportunity 
for intervention.
    Similarly, more than a third of the decedents were reported 
to be very socially isolated or living alone, suggesting that 
providing some social supports might have been helpful. There 
are some papers in the research literature to suggest that with 
some fairly low-cost kinds of interventions to address that 
social isolation issue, we can make a real difference in 
people's lives.
    But there isn't really a single intervention that is going 
to fix this problem. There is no pill that we are going to give 
out that is going to solve this whole thing. We really need a 
multi-faceted approach, and I think in accord with what we 
learned from our Oregon data, our plan is divided into two main 
groups of strategies--clinically based suicide prevention 
activities and community-based suicide prevention.
    Some of the examples of clinically based suicide prevention 
you have already heard about, but in the community-based area, 
programs to increase public awareness about the problem, reduce 
social isolation and provide social services to help older 
adults cope with challenges they may be facing. This kind of 
multidisciplinary collaboration is really critical.
    So while this may seem like a sad topic, I want to tell you 
that it has been incredibly invigorating and exciting for our 
group to be working on this. The need is enormous out there. 
People recognize this, and the response from the community and 
from health care and social service providers has been 
tremendous.
    So I want to ask both of you to continue to call attention 
to this problem, as you are doing today, and to integrate your 
awareness of this problem with the other aspects of services to 
seniors that you might hear about in this Committee. Of course, 
all of this work takes resources and I hope that you will 
continue supporting funding for efforts to address this problem 
particularly at the State and local level.
    Thank you.
    [The prepared statement of Dr. Kohn follows:]

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    The Chairman. Thank you.
    Dr. Walaszek.

    STATEMENT OF ART WALASZEK, M.D., ASSISTANT PROFESSOR OF 
   PSYCHIATRY AND DIRECTOR OF PSYCHIATRY RESIDENCY TRAINING, 
 UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH, 
                          MADISON, WI

    Dr. Walaszek. Mr. Chairman, Ranking Member Kohl and members 
of the Committee, thank you for the invitation to testify 
before the Committee this morning.
    I would like to share my experiences as a physician working 
on the front lines of geriatric mental health care. I work on a 
daily basis with older adults who are suffering from depression 
and suicidal thinking. I work with their family members, who 
must watch as their loved ones struggle with depression, a 
devastating and potentially lethal disease. I work with medical 
students and residents, in other words, with the doctors who 
will soon be taking care of older adults. I would like to share 
my concerns based on these various experiences and my concerns 
about our ability to address late-life depression and break the 
cycle of senior suicide.
    First, my patients face a number of barriers as they seek 
care for depression. I would like to illustrate this by 
presenting a typical clinical scenario. A 70-year-old married 
retired gentleman has lost interest in activities, is sad 
everyday and has withdrawn from his wife, children and 
grandchildren. In the face of a number of medical problems--
heart disease, high blood pressure, chronic pain--he has become 
hopeless and even harbored thoughts that life isn't worth 
living. He has clinical depression and clearly is at risk of 
suicide. How does he, in fact, get help?
    First, he will have to overcome a double stigma: stigma 
about aging and stigma about mental illness. Our society tells 
him that decline and depression are a part of aging. He may 
have his own internal beliefs that he is not ill, that he 
doesn't need treatment, and his low energy, low motivation and 
low interest--all symptoms of depression--may prevent him from 
talking to someone about depression.
    Second, once he has made the step to seek care, perhaps 
with the help of family members, he will need to get diagnosed. 
How will that happen? Well, as you have heard, primary care may 
be the best site to identify older adults who are at risk of 
suicide. My 70-year-old patient goes to his primary care 
provider, who may have the best intentions to provide high-
quality care. But it turns out that during his visit, they have 
to talk about heart disease, high blood pressure, medications 
for pain, exercise, eating right, losing weight, stopping 
smoking, and all in 15 minutes. So it wouldn't be surprising if 
depression didn't come up, and that would be an awful missed 
opportunity to possibly save this gentleman's life.
    Third, let's say he has been diagnosed as having 
depression. The next barrier is treatment. Anti-depressant 
medications are safe and effective treatments for depression. 
The Medicare prescription drug plan has helped some of my 
patients afford medications they couldn't before, but as you 
have heard, some of them are now heading into the ``donut 
hole''. Furthermore, the complexity of the system can vex older 
adults suffering from depression, which affects their 
concentration, their memory and their ability to make 
decisions.
    Finally, psychotherapy or talking therapy is an evidence-
based treatment for depression and was incorporated into the 
IMPACT model that Dr. Steffens described. It works and it 
reduces suicidal thoughts. Yet, Medicare's fee structure, 
whereby only 50 percent of mental health services are covered, 
poses a financial barrier to my patient, who may be on a fixed 
income and has other rising costs and makes the decision not to 
seek psychotherapy as a type of treatment.
    Furthermore, qualified therapists who must themselves raise 
their own families and run their own businesses may not seek 
Medicare patients because the reimbursement is too low. So 
there may be a double barrier in terms of my patient being able 
to get what is a standard of care, psychotherapy, for 
depression.
    We are soon going to face an even bigger barrier. Although 
the number of older adults needing medical care is going up, 
the number of clinicians who can treat them is going down. I 
have seen this myself from the time when I was in medical 
school when the focus was on getting medical students into 
primary care, to now, where a minority of medical students are 
going to eventually end up in primary care. At this rate, I 
don't see how we are going to have anywhere close to the number 
of clinicians treating older adults that we need.
    The Chairman. If they do go into primary care, are they 
going to know how to treat them?
    Dr. Walaszek. That is an additional question, absolutely.
    In closing, I thank the Committee for addressing the issue 
of late-life suicide. Without immediate intervention on many 
fronts, my patients will face growing barriers to treating 
depression and reducing the risk of suicide. I worry about them 
and I worry about my practice, my ability to provide high-
quality medical care and thereby fulfill my duty to alleviate 
the suffering of older adults.
    Thank you.
    [The prepared statement of Dr. Walaszek follows:]
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    The Chairman. Thank you very much.
    Dr. Shern.

    STATEMENT OF DAVID SHERN, PRESIDENT AND CHIEF EXECUTIVE 
  OFFICER, NATIONAL MENTAL HEALTH ASSOCIATION, ALEXANDRIA, VA

    Mr. Shern. Chairman Smith, Senator Kohl, thank you so much. 
It is wonderful to be here today, and happy birthday. I am the 
president of the National Mental Health Association and have 
held this position now for 10 days. So I am learning an awful 
lot about the Mental Health Association and about Washington 
traffic. I had just a delightful drive in this morning down 
395.
    The Chairman. Would you say that contributes to mental 
health difficulties? [Laughter.]
    Mr. Shern. I have an enormous sense of wellness right now, 
having sat in traffic and being late for my first-ever 
opportunity to testify to a Senate committee. It is a great 
honor to be here.
    Senator Smith, I have had the opportunity to meet you and 
your wife on other occasions, and the kind of inspirational 
leadership that you have in taking the horrible thing that 
happened to you in your life and making it into something that 
changes other people's lives is an inspiration to all of us and 
it makes an enormous difference.
    The panel has done a spectacular job of summarizing the 
issues, that we need to confront. The biggest issue is taking 
our considerable research base--we need more work--and figuring 
out how to get it in action. Prior to joining the NMHA, I was 
also a dean. So I am a dean in early stages of recovery. I 
chose to leave academia, which was an extremely difficult 
decision for me because I felt that this opportunity at the 
National Mental Health Association would give me a direct 
chance to try to move research into action through public 
education and policy advocacy.
    There is no area where the issues are clearer than in the 
integration of general health and mental health within a single 
concept, and taking our considerable research base and putting 
it in place. As everybody has mentioned this morning, mental 
health problems are not trivial problems; they are fatal 
problems. These problems kill lots of people every year. We 
could characterize the situation as really a national 
embarrassment. That we continue, with the technology and 
information we have, to allow 30,000 people a year to die by 
suicide should be shameful for us as a society.
    One of the mental health themes that we always talk about 
is stigma, ignorance and discrimination. In fact, it is so 
important that we are launching a national public information 
campaign today. At exactly this same moment, at the National 
Press Club, we're announcing the ``Depression Is Real'' 
campaign, and this campaign reflects a seven-member coalition, 
including the National Mental Health Association, the National 
Alliance on Mental Illness, the American Psychiatric 
Foundation, the Depression and Bipolar Support Alliance, the 
Urban League, LULAC, and the National Medical Association, each 
of which is committed to drilling this message to the general 
public that depression is real, it is identifiable, it is 
treatable, and that we waste an enormous amount of our human 
capital by not effectively recognizing and treating depression, 
which would have direct effects on driving down the suicide 
rate.
    The groups that the National Mental Health Association is 
collaborating with on this particular initiative, reflect 
minority groups in important measure. As you all know, if we 
look at people of color in this Nation, we find great 
disparities in terms of their access to health care and mental 
health care, and we find great disparities in terms of their 
health status. They don't do as well. That lack of access 
causes problems.
    Older adults, with regard to mental health care, would fall 
right into that category. There are enormous disparities with 
regard to their access to care; there have been for years. The 
demographic comparative everybody has been talking about is as 
clear as it can possibly be. The baby-boomers, and I consider 
myself among them, are marching toward our older years and 
unless we develop more effective strategies to deal with these 
issues, we are going to be in big trouble.
    People today have highlighted several of the models that 
are available. We have a model at the Florida Mental Health 
Institute FMHI which we developed for alcohol and substance 
abuse treatment that works with elders in the settings in which 
they show up, rather than trying to get them to go to specialty 
settings. It doesn't focus on primary care. It focuses on aging 
centers and other areas where elders congregate. It is very 
low-intensity, inexpensive to try to recognize and treat 
alcoholism and prescription drug abuse, which you know are also 
real problems in elders.
    Our colleagues at Cornell are developing programs to use 
natural helpers, people like home visitors, Meals on Wheels, to 
try to get some new systems of care in place utilizing a 
broader base of workforce and non-traditional settings to reach 
out to people who have traditionally not chosen to participate 
in care.
    I will end by bringing us back to parity because it is 
fundamental. It fundamentally reflects in our statutes, in our 
policies, in our State regulations the discrimination against 
these disorders. As the Surgeon General said, health is 
fundamental. Mental health is fundamental to health; they are 
not separate things. We cannot deal with them separately and we 
cannot continue to tolerate this discrimination statutorily 
built into our programs. One I will point out is the Medicare 
program, where there is a $50 co-pay for specialty mental 
health services, as opposed to a $20 co-pay for general health 
services. That is not acceptable.
    It has been a great honor to be here. This is a huge 
problem. I am committed, and all of our allies are, to making a 
difference in this area and I am confident, with your 
leadership, we will be able to really move the needle on this 
issue.
    [The prepared statement of Mr. Shern follows:]
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    The Chairman. David, I think your point--and all of you 
have made it, I believe--about the discrimination that exists 
in American law, Medicare, Medicaid, when it comes to mental 
health is truly beyond absurd; it is now an embarrassment. 
There really should be no higher issue of priority for us in 
Congress when we take up health care than to fix this. Please 
know that is No. 1 on my list.
    Mr. Shern. I think it is in our enlightened self-interest 
to do that. I think ultimately we will get healthier, more 
productive communities.
    The Chairman. Yes.
    Mr. Shern. Depression is, by 2010, going to be the most 
disabling illness, period, of all illnesses, according to the 
World Health Organization. If we continue to leave it 
untreated, we are just wasting enormous amounts of human 
capital. Those kinds of estimates need to be factored into 
these cost equations. We can't simply look at revenue 
expenditure.
    The Chairman. In addition to pharmaceutical parity, you 
would add teaching parity, and how about research parity?
    Mr. Shern. Absolutely, all of those things.
    The Chairman. Insurance parity is another issue, but we 
have not been able to get that through the bicameral system 
here. But we would add that as well along with insurance, 
research, pharmaceutical and teaching parity--if we are really 
going to be serious about addressing this issue.
    Mr. Shern. I agree.
    The Chairman. I guess that is our job. We have got to march 
in order, Senator Kohl.
    David, you talk about this being a national embarrassment. 
Are there other nations, in your experience, in research that 
are doing this well?
    Mr. Shern. You know, it is very interesting. Let's talk 
about schizophrenia for a second rather than depression. The 
World Health Organization has done an international study of 
people with schizophrenia and one of the most surprising 
results from that study is that persons who have 
schizophrenia--and this is again using a standardized 
diagnostic technique culturally appropriate, so they have done 
the science all right.
    One of the most surprising findings from this international 
study is that people who have schizophrenia in Third World 
nations, in developing nations, actually have a much better 
course than people who have schizophrenia in First World 
nations. Now, we are not sure exactly why that is, and like all 
scientific findings, there are some nuances that I am glossing 
over a bit, but it is a main effect; we find it.
    Some people feel that it is because in Third World nations 
we can't marginalize people from our communities. Everybody's 
labor has to be involved if the community and the family is 
going to be successful, whereas in First World nations we have 
systems of disability that require people essentially to make 
public declarations that they are no longer able to contribute 
to their community or to their society in order to get basic 
health care and a basic below-subsistence income.
    So it could be that as we look at some of the 
counterintuitive effects that we have with well-intentioned 
policies like the Social Security disability program, which is 
extraordinarily important. We need to think about somehow 
aligning these incentives differently so that we no longer 
marginalize people with severe disorders so they can engage 
productively in their community. There are other international 
differences, but I think for me that is a really important 
theme.
    The Chairman. It sounds to me like you are saying it is not 
just a national embarrassment, it is a worldwide embarrassment 
that we are not doing better.
    Mr. Shern. Yes.
    The Chairman. Dr. Colenda, the four points you made--I have 
made note of those and we are going to add those others that I 
didn't mention to David; we are going to add those to our 
priority list as well.
    In my dealings with seniors, when you have occasion to go 
and look in their medicine cabinet, it is just astonishing how 
many medicines they are taking. I wonder from your scientific 
perspective, is there like a pharmacological brew that has 
unintended effects on people's mental health? Is the 
understanding of mental health well enough known so that as 
doctors are prescribing all these other things for various 
aches and pains, they may be fueling depression?
    Dr. Colenda. Yes. I think that as I used to say to my 
residents and fellows, less is best. One of the things that we 
try to train our folks on is that pharmacology in late life is 
a complicated management issue for physicians to become 
familiar with. Quite frankly, many physicians do not understand 
the nuances of pharmacology for elders.
    I can give a personal example. My father was on a 
medication prior to his death that was given at the same dose 
that one would give to a 45-year-old healthy person, and he was 
88 and he got toxic from it. Not being a quiet, retiring 
individual, I went thermo-nuclear with his primary care 
physician. That primary care physician was well-trained. He 
went to my medical school, and I was astounded that he was 
using a dose for a 45-year-old in an 88-year-old.
    So there is a tremendous gap between knowledge and 
practice, between what we know how to do and what we do in 
pharmacology. Certainly multiple medications can lead to 
things, not only to depression, but also to cognitive 
impairment, because many of the drugs that are prescribed have 
effects on brain functioning.
    The Chairman. Senator Kohl may need to leave shortly and I 
am going to follow with a second round because I have more 
questions.
    Senator Kohl, please.
    Senator Kohl. Thank you, Mr. Chairman.
    Gentlemen, listening to you all, you point out the fact 
that most people or a majority of those who commit suicide have 
seen a physician within a month or 2 months before they 
committed suicide. You have talked about physicians who are 
knowledgeable with respect to high blood pressure and all the 
other chronic diseases that our seniors face, but isn't it true 
that if they were sufficiently knowledgeable and empowered to 
do the same kind of an analysis and examination of their 
psychiatric health, this problem, while never being eliminated, 
would be reduced significantly? Isn't this going to have to 
happen in order for us to get to an alleviation of the problem 
of senior suicide? I mean, isn't that a must that we need to be 
sure that our physicians are qualified, capable and interested 
in diagnosing and treating the problem just as they do with 
heart problems? Isn't that right?
    Dr. Colenda. Yes, sir, Senator Kohl, and it starts from day 
one of medical school and it needs to continue through 
continuing medical education. Fortunately, in medicine today we 
are going toward what we call competency-based education, 
demonstrating that a physician knows what he or she needs to 
know for that particular series of illnesses.
    As you heard from Dr. Steffens, primary care physicians are 
the front lines of health care in this country, and when they 
are scheduled for basically 7- to 8-minute office visits, 
trying to discover significant mental health issues in late 
life takes time, and time is of the essence for them in terms 
of running their busy practices. So we have looked toward 
collaborative care models to help with providing experts that 
assist primary care physicians to do the right thing.
    They want to do the right thing. They are dedicated health 
care professionals. But time is a major problem, and there are 
two ways to get reimbursed in Medicare right now--volume or 
technology. The only way that you can do volume is shorter and 
shorter periods of time.
    Senator Kohl. So it is not the seniors' fault, it is our 
fault. Isn't that right?
    Dr. Colenda. Well, there is a whole body of literature on 
breast cancer research that has looked at how to help breast 
cancer patients be actively involved in the decision for their 
treatment. It is decision support programs for patients. In 
terms of dissemination of this, we need to be publicly and 
actively destigmatize mental illness in late life and say it is 
OK to go in to your doctor and say, you know, I am not feeling 
really good and it may be that I am sad and depressed, which 
keys the physician to do what he or she knows how to do.
    Dr. Walaszek. We have devoted a lot of resources to 
teaching people about the signs of heart disease, having a 
heart attack, looking for those signs of chest pain, and that 
has been a tremendous investment and it has saved a lot of 
lives. I think we can do something similar to teach people and 
their family members about recognizing the warning signs of 
depression and suicide, and again to break down that stigma to 
make it easier to approach someone's primary care provider not 
just because they are in pain or they are feeling nauseous or 
they need a refill of their medications, but because, in fact, 
they have been feeling sad and down and thinking about ending 
their lives recently.
    Mr. Shern. Could I just add a couple of quick thoughts, one 
follows on Chris's notion about picking up on the continuing 
medical education. We need to do that in a fundamentally 
different way than we have done it in the past. You know, we 
use methodologies that are oftentimes called spray and pray. 
You spray training on people and you pray some of it sticks.
    We need more systematic ways to follow up and support 
people in their practices. Hopefully we are rapidly developing 
the kind of electronic medical record systems that we need in 
this country. I am sure you all have thought a lot about that 
because it is a huge problem. It is amazing that I can go to 
Hong Kong and stick in my ATM card and get Hong Kong money and 
get my checkbook balance. But when I go to the doctor, I fill 
out, typically, an old blue form. The disconnect there is 
enormous.
    When we start to make that kind of data available, we can 
support people in making better decisions. We can prompt 
primary care physicians so they don't have to try to remember 
everything. We can prompt them and help them look at the risk 
factors for a particular patient in a much more efficient way.
    The other thing we are learning, which I think is dramatic 
and I hope is really going to start to change this 
conversation, is the importance of comorbidities, of people who 
have more than one condition. We now know that if you have 
cardiac disease and depression, having the depression will 
predict dramatically different outcomes for you. You are much 
more likely to die if you have cardiac disease and depression 
than a person who only has cardiac disease.
    As we start to appreciate the complexity of the whole 
person, Senator Kohl, this will also give a chance to better 
integrate our thinking and destigmatize these illnesses, when 
you start to see what happens when you add them concurrently to 
a condition that no one would question in terms of its 
legitimacy. I think that will also help us improve practice.
    Senator Kohl. Thank you very much, and thank you, Mr. 
Chairman.
    The Chairman. Thank you, Senator Kohl.
    I have got a bunch of additional questions and apparently 
the vote isn't going to be immediately, probably 15 minutes or 
so, so I would like to take advantage of your being here.
    Dr. Colenda, in addition to the four things you asked us to 
look at, I am interested in your--and, Art, you may have a 
comment on this, too. You are both in medical schools right 
now. What are the minimum psychiatric requirements for someone 
going into general practice today?
    Dr. Colenda. If you look at the Liaison Committee for 
Medical Education Requirements, for medical schools--the 
requirement is that students must have ``adequate experience in 
psychiatry,'' as defined by general competencies; that is, 
diagnosing mental illness, being able to conduct an interview 
and learning fundamentals of treatments.
    The average experience in psychiatry in medical schools in 
the country is about 5 weeks. That is compared to 12 weeks in 
medicine, 12 weeks in surgery. The competition for time in the 
curriculum is such that with the explosion in technology and 
genetics and molecular medicine, there has been an increasing 
compression of time on things like psychiatry, neurology and 
other types of specialties that have historically had larger 
amounts of time in the curriculum.
    In primary care residencies, in family medicine, there is 
no required psychiatry rotation, but they do have to have 
certain general competencies met as part of their requirements 
for completion of residencies. It is similar to the spray-and-
pray concept. We are trying to move from a fixed amount of time 
in the curriculum to demonstrating that Chris Colenda as a 
third-year medical student knows how to conduct an interview, 
knows how to diagnose major illnesses. Then Chris Colenda as a 
resident in primary care knows how to manage depression in a 
community setting, and that competency is then reinforced 
throughout time. We have the tools to do that, but it has been 
incredibly slow to try to move that forward because of the 
competition for time in our training programs, whether it is 
medical school or residency training.
    The Chairman. As Art pointed out, we have got a baby-boom 
generation about to become seniors, and you have pointed out 
the economics aren't there in mental health. Assuming the 
Federal Government can purge the discrimination from the 
various policies we have, it seems to me that it is imperative 
that medical schools understand where the puck is going, where 
the ball is going, and the ball has got to be going in your 
direction. We have to get our policies in line with where the 
economics are going to be, and there are going to be in the 
geriatric field and in the mental health field.
    So I wonder if you have a comment, Art, about that.
    Dr. Walaszek. Senator, I would like to make a comment about 
fragmentation of the medical system and how that is actually in 
parallel with how medical training occurs. You commented on all 
the different medications that you find in the prescription 
cabinet, and that is often because someone sees a cardiologist 
who prescribes three medications, a primary care doctor who is 
in charge of a couple of more, and a pulmonologist who adds a 
couple more.
    Just practicing on a daily basis, it is very hard to keep 
track of all of that, to keep all these folks in sync with each 
other and making sure that their medications are not 
interacting with each other and causing problems. You see that 
in medical training. These tend to be block experiences in the 
third and fourth year. You do your time in surgery, you do your 
time in medicine, you do your time in pediatrics, without 
getting a sense of what it is actually like to practice, which 
is that you are juggling many different things at the same 
time.
    So as a dean, I don't know how realistic, Dr. Colenda, it 
is to see if that is going to change any, but it would seem 
that that would need to be a fundamental change in medical 
training.
    Dr. Colenda. Medical education is under going reform. The 
last major reform was at the beginning of the 20th century. My 
hope is that the next major reform will be at the beginning of 
the 21st century. Hospital systems have gone to service lines, 
where it is integrated care. If you go into a hospital today, 
for heart disease at a major academic medical center, you get 
admitted to it is the cardiovascular service line. So you have 
cardiovascular surgeons, the cardiologist, the rehabilitation 
folks all working together to provide a continuity of care 
within a particular service line.
    We still are in the mode of, as Art says, 12 weeks of 
medicine, 12 weeks of surgery. We need to move toward an 
integrated system of care because that is how docs are going to 
practice in the future. Now, as a dean, you would think that I 
have some control over the curriculum. I have a thousand points 
of ``no'' and they are called faculty.
    The Chairman. So you are in politics, too. [Laughter.]
    Dr. Colenda. Yes, sir, and it is persuasion and guile and 
bribery and all the good things that my mother said I should 
not do as a physician. At Texas A&M Health Sciences Center, I 
am proud that we are making substantial changes in our 
curriculum that are pointing people toward the 21st century 
practice of medicine and not the 20th century practice of 
medicine.
    The Chairman. Mel, I have a hard question for you. First of 
all, happy birthday.
    Dr. Kohn. Thank you.
    The Chairman. You and I come from, I think, the best of the 
50 States, but we also have a law that allows physicians to 
assist in suicide. Now, let me be very careful to say for the 
record that that is the will of the people of Oregon, and that 
will has been affirmed by the United States Supreme Court and 
Congress is not going to change that.
    Given that law, how does that affect your work to prevent 
what we make legal?
    Dr. Kohn. Well, Senator Smith, I guess I would say one of 
the main ways it affects my work is that every time we talk 
about suicide, as somebody from Oregon, this issue gets raised. 
I think in many ways it is unfortunate that the two issues get 
mixed together because we are talking about in my mind two 
things, two patterns of behavior that really are very 
different.
    The Chairman. But you find anecdotally it is mixed all the 
time, and I do in every town hall where the issue comes up.
    Dr. Kohn. In terms of our data, by law, according to the 
Oregon law, deaths under Oregon's Death With Dignity Act are 
not counted as suicides. So the numbers I gave to you before or 
any of the numbers that you see reported in either our data or 
the national data that come from our data--those deaths are not 
included in our counts for suicide.
    The Chairman. Yet without those numbers, we are the fourth 
highest in the Nation for senior suicide.
    Dr. Kohn. It is an enormous problem for us.
    The Chairman. There is an old maxim in lawmaking that 
whatever you legalize, you normalize and incentivize. Is that a 
problem in your work?
    Dr. Kohn. Well, when we look at the rates of suicide in 
Oregon over time, there has essentially been no change in the 
rates with the enactment of the Death With Dignity Act in 
Oregon. So I wish that the rates were dropping precipitously in 
Oregon, but they have continued to be high in Oregon both with 
and without the law.
    The Chairman. I appreciate your answer to that. It is a 
very difficult issue. They are apples-and-oranges issues, but I 
know in politics perception is reality, and that is how it is 
perceived not just in Oregon, but around the country, that we 
are sort of at cross-purposes.
    I am aware that SAMHSA awarded Oregon $100,000 in 
recognition of your and your agency's leadership in the area of 
suicide prevention. I wonder if you can tell us how you will 
use the money. Has it helped?
    Dr. Kohn. Thank you, Senator. Yes, we did get that grant 
from SAMHSA and we have been using it in two ways. The first is 
along the lines of the discussion that we have already had in 
the Committee this morning to put together a training program 
for Oregon physicians, particularly primary care physicians, 
around this issue, and we are in the process of developing and 
launching that.
    The other thing that we have been doing is working on 
disseminating the plan more widely, and by that I mean getting 
more people engaged on this issue. We are going to be holding a 
series of community forums around the State. One of the things 
that I think is very clear to us is that this is an issue that 
needs to be addressed not just by the medical community, but by 
all of the service networks that we have that touch seniors' 
lives.
    Dr. Shern referred to some of the other folks who come in 
contract with seniors who can be important gatekeepers and 
encouragers of people getting the treatment that they need. So 
part of the work that we are doing with communities around the 
State is to get these other networks of providers on board and 
engaged and using their resources to address this problem as 
well.
    The Chairman. Well, we appreciate so much what you are 
doing in this area. Suicide is just such a tragic outcome, 
particularly when it is entirely, utterly preventable. This 
hearing this morning has identified a lot of concrete things we 
can do at the Federal level, what you are doing at the State 
level, and certainly what we need to do at the university 
level, because this problem is not going away. It is going to 
get bigger as this population gets bigger, and we have got to 
have a better program and better answers than we are currently 
providing at every level of medicine and government.
    So I simply want to express to each of you how much I value 
your work and honor your profession. You are on the side of the 
angels as far as I am concerned. Whether it is a senior at 85 
or a teenager at 18, we have got to do a better job.
    To David's point earlier, we have a societal interest in 
this. I mean, some of the greatest people and leaders in 
history have been manic depressives. Abraham Lincoln comes to 
mind. Meriwether Lewis, of the Lewis and Clark expedition, was 
undoubtedly a manic depressive who at the end of the journey 
blew his brains out--actually, he shot himself in the heart, 
but tragic; I mean, a very gifted and bright man. Winston 
Churchill used to speak of it as his black dog. So there are a 
lot of bright lights we need to keep on running brightly, and 
you are on the front lines.
    So we thank you for spending your time with us. You have 
given us specific things to do and we will do our best to do 
them. Parity is an issue that is on my mind every time I get up 
in the morning. At the research, the medicine cabinet, the 
teaching and the insurance levels, we need to change our 
policies in the Federal Government, and count on you guys to 
change the medical schools and fight that political battle. I 
don't know which is harder, in higher ed or in Washington, DC, 
but it is politics of the first order. But it is a life-and-
death issue that you have to win and also one that we have to 
win here on the Hill.
    So with that, I would again express our genuine thanks, and 
happy birthday, Mel. So Chris, Mel, Art, David, physicians and 
doctors all, thank you, and we are adjourned.
    [Whereupon, at 11:18 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


               Prepared Statement of Senator Ken Salazar

    I thank Chairman Smith and Ranking Member Kohl for holding 
these hearings--to address the troubling suicides rates among 
America's seniors, and learn more about what we can do to 
reverse them.
    Recent studies continue to highlight disturbing trends in 
the suicide rates for older Americans. Loneliness, a loss of 
autonomy and independence, and anxiety about mounting bills and 
financial obligations contribute to the sense of hopelessness 
that ultimately drive seniors to end their lives. These are 
deeply personal matters, and many seniors are reluctant to 
express their thoughts and ask for help.
    However, as policy makers, I do not believe that we are 
powerless to help mitigate these effects. In the 1930's, with 
the implementation of New Deal programs designed to provide a 
financial safety net for Americans as they reach retirement, 
America saw a dramatic down turn in the rates of senior 
suicides. This trend has continued through the past decades 
with the creation of the Medicare program and the Older 
Americans Act.
    These important programs have helped to provide seniors 
with invaluable aid as they retire, assistance to receive the 
medications they need--and communicates a message that they are 
not alone, and America will not abandon the promises it has 
made to care for them and see that they age with dignity.
    The Senior Community Service and Employment Program--under 
the Older Americans Act--has been a great example in my home 
state of Colorado, and throughout the country, of the value of 
such senior programs. The SCSEP program not only helps low-
income seniors develop the necessary skills to re-enter the 
workforce, it also helps to renew the individual's sense of 
self worth. These factors decrease the risk of depression among 
seniors--and lower the risk of suicide.
    We have a duty to continue the legacy of these programs and 
honor the promises our generation has made to generations 
before us. The fact that the American population continues to 
age with the baby boomer generation implies that these programs 
are more important than ever, and we must strengthen our 
resolve to protect and enhance them.
    Community organizations at the local and national level 
have played an important role in preventing suicide, educating 
the public, and bringing the issue of suicide prevention to the 
forefront. Activity within my home state of Colorado on this 
front has been tremendous--and I am pleased to see that the 
Suicide Prevention Resource Center is holding their annual 
conference for many western states in Colorado this October.
    However, despite these important advances, suicide rates 
among senior citizens, particularly white males, continue to be 
much greater than the suicide rates of every other age group.
    At the personal level, early identification of suicide risk 
factors is key to mitigating and preventing elder suicides. 
Identifying these risk factors is shared by many parties--from 
primary care physicians, and long term care providers--to 
family members and community care organizations.
    Increasing the accessibility of seniors to affordable 
healthcare and prescription drugs, combined with greater access 
to mental health services will continue to be critical in 
identifying these factors, as well as increasing help seeking 
behavior.
    I look forward to the testimony and insight from today's 
panel of expert witnesses on these fronts to further illuminate 
this problem, and discuss what steps we can take to reverse 
this current trend.
    Thank you again.

                                 
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