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Belmont Behavioral Health, part of the Einstein Healthcare Network, has a team of geriatric mental health experts that
works with the growing population of elders with unique mental health needs. Belmont offers an integrated system of care for
older patients, including inpatient and outpatient settings, four outpatient group therapy programs, services for those with
substance abuse disorders and services for those with significant co-morbidities.
Addressing both recent and longstanding mental health problems
The expected increase in older adults seeking mental health services stems from a variety of needs, says Belmont psychologist
William Shapiro, PsyD. Some may have chronic mental health problems, while others may have developed recent problems or are
suffering anxiety related to the social and physiological processes of aging.
“After suffering some kind of loss, many older patients come to us with depression,” says Dr. Shapiro. “They may have had
recent personal losses, loss of functioning, or may be mourning the loss of youth. Many are struggling with issues common
to aging, such as loss of independence and control. At times, anxiety may have led to problems with substance abuse, perhaps
abuse of prescription medications, drugs or alcohol.”
Dr. Shapiro emphasizes the importance of primary care physicians being alert for status changes in their older patients, as
many will not readily come forward about their emotional issues. A little ‘digging’ may be required to determine if someone
is suffering with emotional or mental health issues, issues that might cause depression and impact overall level of functioning.
Seeing through a ‘cloud of medications’
Belmont physicians and staff who treat geriatric patients pride themselves on treating the “whole” person, not just symptoms,
to determine what Dr. Zisselman calls the nuances of depression. “A multi-modal approach to figuring out the etiology is required,”
says Zisselman. Often, that approach means seeing through a cloud of medications.
Psychiatrist Sook Hee Yoo, MD, is always watchful for patients who come to Belmont overmedicated or those who have been taking
their medications inappropriately and have resulting drug-induced depression or other symptoms. “Some older patients come
to us taking as many as 20 overlapping medications,” says Dr. Yoo, who has been practicing at Belmont for 34 years and estimates
that up to half the older patients she and her colleagues see are overmedicated. “Often we give them a ‘drug holiday’ in order
to find a baseline. We will eliminate prescription drugs one by one and carefully watch the response, then start low and go
slowly when restarting medications.”
Yet, sometimes the difficulty lies with even appropriate prescription drugs because, as Dr. Yoo explains, older patients metabolize
psychotropic drugs differently than younger patients.
Conditions associated with depression in the elderly
Sorting out depression and dementia is another challenge. “Our patients often present with depression and complications from
dementia,” says Dr. Zisselman. “Changes in mental status, such as confusion or anxiety, warrant immediate attention.”
Dr. Zisselman emphasizes that he and his colleagues look very closely during evaluations in order to sort out the cause of
depression and what might be impacting overall functioning.
Often, says Dr. Shapiro, patients come to Belmont with a dual diagnosis, such as depression and substance abuse problems.
Recent statistics estimate that up to 17 percent of older adult patients have substance abuse problems. Physicians and therapists
at Belmont are also keenly aware of clinical co-morbidities, such as heart disease, which is now associated with depression.
Many times electroconvulsive therapy (ECT) is prescribed as an adjuvant treatment or in place of pharmacological treatment.
“Studies show that ECT is safe and very effective in older adults,” confirms Dr. Zisselman. “It’s recommended for those who
have failed two antidepressants. It is a treatment that is always on the table at admittance and early on I explain it to
patients and their families as a treatment option. Usually, the positive results come faster than they do with medication.
A broad range of therapies for older adults
The range of therapies available to older patients at Belmont is broad, whether patients are admitted as inpatients or as
outpatients. “Everyone receives an in-depth evaluation,” explains Dr. Shapiro. “The evaluation is by a multidisciplinary care
team that includes not only the psychiatrist but a psychologist, social worker and other licensed therapists. The psychiatrist
determines the diagnosis and orders treatment of the appropriate intensity and frequency.”
Individual as well a group therapy is available, says Dr. Shapiro. For those for whom it is appropriate, group therapy can
be a great help. “Being part of a group, being part of something larger than oneself, can be very therapeutic,” suggests Shapiro.
“Seeing that others are struggling with similar issues, or being helpful to someone else can also be therapeutic.” Groups
of eight to ten patients – based on what is best for the patients – may constitute a group. If clinically indicated, family
members are also seen for family therapy.
Tailoring treatment programs to the individual older adult
At any one time, the geriatric mental health service at Belmont may be treating 200 outpatients in four units designed to
meet patient needs. Groups are created based on whether patients are fully ambulatory or less so and whether the patients
have been struggling with chronic mental illnesses throughout their lives or are having more recent issues related to aging
and mental health.
Inpatient treatment is not always necessary or desirable, and outpatient programs are designed with the patient in mind. Outpatient
treatment is tailored to the patient and the patient’s problem. Older patients who are recovering from strokes or patients
with a lifetime history of bipolar disorder or schizophrenia would not, for example, be placed in group therapy with an older
adult who, while suffering from depression, continues to be employed, to drive a car, and to have an otherwise normal life.
“We place people in the treatment program where they are best served,” says Dr. Shapiro. “We provide a continuum of care where
inpatients may seamlessly step-down to outpatient programs.”
Mental health issues for the older adult patient can be not only complicated but easily misunderstood, suggests Dr. Yoo. She
and her colleagues are acutely aware that aging in Western cultures is fraught with social issues that can readily affect
mental and emotional status and can contribute as an underlying cause for depression.
“Older people often lose respect and, in a youth-oriented culture, may feel shame and a loss of self-respect with aging,”
says Dr. Yoo. “We provide a caring and supportive environment that can help.”
Keeping the lines of communication open
Physicians who refer their older adult patients to Belmont can be assured, says Dr. Zisselman, that the communication lines
between them and the physicians and therapists at Belmont will be open and updates will be frequent. For Dr. Zisselman, who
oversees the outpatient program at Belmont, such communication with both families and referring physicians, along with a multidisciplinary
approach to treatment, is the key to success. “We recognize and treat every patient as an individual,” concludes Dr. Zisselman.
“Whether an inpatient, outpatient or a patient in a partial hospital program, our goal is to determine the appropriate level
of care for each and every patient and deliver it in a caring and supportive way.”
Belmont Behavioral Health is one of the largest, most comprehensive behavioral health systems in Philadelphia. For 70 years,
Belmont has provided compassionate, quality behavioral health care to people of all ages. To learn more about our services
and locations, call 215-877-2000.
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