"What a Good Idea!"
How I got Started
Geriatric Psychiatry has been a wonderful career. I started providing psychiatric services to older people in 1977. One of my first jobs after finishing my psychiatric training was in the outpatient clinic of the Jewish Home of Miami. They had established outpatient psychiatric and medical clinics to provide services for people on the waiting list for admission to their long-term care nursing home. This psychiatric clinic for the elderly was a unique program for that time, established by Dr. Jack Skigen, who at the time was the only psychiatrist in Miami seeing geriatric patients.
Geriatric Psychiatry had only a minimal presence in the United States before the 1970’s. There was only one Fellowship training program in Geriatric Psychiatry, at Duke University, and only one local (in Boston) psychiatric journal devoted to the elderly. Textbooks focusing on this area were practically nonexistent. The National Institute on Aging (NIA) had just been founded in 1974, and the National Institute of Mental Health (NIMH) Center for Studies of the Mental Health of the Aging in 1975. The American Association for Geriatric Psychiatry (AAGP) was founded the following year, in 1978, and the American Psychiatric Association’s Council on Aging in 1980. The first Board Certification examination in Geriatric Psychiatry was not given until 1981.
During the 43 years of my career so far, I have focused almost entirely on taking care of older people and their psychiatric problems. For 33 of those years, I had an active outpatient private practice in Miami Beach, Florida, which was then a large retirement community. I have cared for older patients in psychiatric hospitals, medical hospitals, nursing homes, assisted living facilities and by visiting them in their homes. In addition, I worked in various administrative capacities, including as Medical Director of the Community Mental Health Center for Miami Beach from 1979-1986, and serving several years as a Medical Director at two of the hospitals on Miami Beach. Between 2010 and 2020, I was Chief of Psychiatry and Medical Director of the Geriatric Psychiatric Hospital at the Jewish Home of San Francisco.
Besides being an active clinician for more than 40 years, and treating thousands of geriatric patients, I have been very involved in the activities of multiple professional organizations focused on older individuals and their mental, emotional and cognitive problems. I served two terms as President of American Association for Geriatric Psychiatry (AAGP), and held offices in other organizations. While President of the AAGP, I initiated the process leading to the creation of the American Board Certification examination in Geriatric Psychiatry.
I taught and lectured and wrote. I was Clinical Professor of Psychiatry at the University of Miami, and then, Clinical Professor of Psychiatry and Behavioral Sciences University of California San Francisco. Among other things, I have had a particular interest in teaching how to be professionally successful taking care of people in late life. My goal has been to encourage and mentor psychiatrists, other doctors and mental health professionals to go into the field of treating older individuals.
I have loved the work that I’ve done with these patients. I have never been bored. Older folks have lived long, unique, interesting lives, and they often have great stories to tell.
Older people are survivors. The U.S. average life expectancy is about 79 years old. That means that anyone who has lived to be 79 has outlived half of the people born at the same time. By definition, that person is a survivor. They have lived through many events and coped with many challenges, and often they have figured out techniques and strategies that they’ve used to deal with those stresses. There have been many times when I helped someone with new difficulties by using some of these coping skills that they had learned earlier in life. Contrary to popular ideas, with help, many older patients can improve and get better, and resume their lives in the community. This is a very hopeful and gratifying aspect of working with this population.
Over the time that I have been working, the field of Geriatric Psychiatry has become better established and recognized, with increasing knowledge about the mental health and illness issues associated with aging, and encouraging the care and treatment of the mental, emotional and cognitive problems of older individuals.
There are now multiple textbooks and journals, organizations and post-graduate training programs and Fellowships in Geriatric Psychiatry, and there is extensive research going on into the psychiatric illnesses and treatments of the elderly.
The need is still great, and growing. As of 2019, 54 million people in the US were over 65 years old, out of a total population of 330 million (16.4%). Over the next 25-30 years, that number is expected to climb to about 100 million, or nearly 25% of US residents. Approximately 15-20% of older people suffer some diagnosable mental or emotional disorder. About 5.5% suffer from a cognitive disorder such as dementia. This is a tremendous number of people! In addition, they have multiple medical problems, and take multiple medications. There are many interactions between medical and psychiatric conditions. Knowledge of potential benefits and potential risks of these can be part of the work of a geriatric psychiatrist. Psychological and social issues are also components of this work. The current and future need for geriatric mental health and geriatric medicine providers is enormous!
Older individuals, and their families, have been sorely distressed by these problems that are so common in late life, and are often eager, and even desperate, to get help with them.
Nonetheless, there are still relatively few mental health practitioners, including psychiatrists, psychologists, nurse practitioners, and others, who are focused on caring for this growing older population. As of 2020, there were only about 1000 members of the American Association for Geriatric Psychiatry, and about 1500 psychiatrists who are currently Board Certified in Geriatric Psychiatry, fewer than one for every 39,000 people over 65. There are an unknown number of psychiatrists who take care of some elderly patients, often for only part of their time. There are only a limited number of psychiatric residents who choose to take an extra year of subspecialty training in Geriatric Psychiatry.
This limited availability of Geriatric Psychiatric providers is a great societal dilemma. People recognize that older folks have need for help with their troubles, but are generally unaware that such help exists.
Furthermore, for legal matters, there are an even smaller number of knowledgeable Geriatric Psychiatric clinicians who are interested and available to consult with elder law and other attorneys. Such cases may involve questions of the complex interactions between psychiatric, medical, and social factors, where this specialized expertise can be key to the understanding of the case. Often Individuals in late life can be vulnerable to fraud and abuse and undue influence. Testamentary capacity and other capabilities may be questioned.
"What a Good Idea"
Although it has been gradually changing, for a long time many people have been somewhat leery of psychiatrists and mental and emotional problems, associated with fantasies about mind reading, or of being “analyzed,” or being thought to be “crazy.” In the past, I have heard that sort of reaction many times when people learn that I am a psychiatrist.
However, when I meet someone and tell them that I am a Geriatric Psychiatrist and that I take care of older folks, almost universally, with delight and sometimes with surprise, their response is, “What a good idea!”
© 2020 Elliot M. Stein, M.D.