As 20% of persons age 55 or older have a mental health condition and the number of older adults who experience substance abuse issues is growing, it is important for this plan to address the unique needs of this cohort in its prevention strategy and consider this an at-risk population (American Association of Geriatric Psychiatry, 2008). The widespread availability of evidence-based interventions that address suicide, depression, and prescription and/or illicit drug misuse or abuse in older adults is critical.

Elderly white males have the highest suicide rate than any other group. Lack of identification and treatment of mental health conditions contribute to this high rate. Nearly one-third of older adults who die from suicide had seen their primary care physician in the week before completing suicide, and seventy percent have seen their doctors within the prior month. 14.3 of every 100,000 people age 65 and older died by suicide in 2004, higher than the rate of about 11 per 100,000 in the general population (U.S. Centers for Disease Control and Prevention, 2009).

Although depression is not a normal part of aging, a disproportionate number of older adults experience this and other forms of mental illness. According to the U.S. Centers for Disease Control and Prevention (2009), among those ages 50 or older, 7.7% reported current depression and 15.7% reported a lifetime diagnosis of depression. Older adults with depression also visit the doctor and emergency room more often, use more medication, incur higher outpatient charges, and stay longer in the hospital longer. However, in 80% of cases, depression is treatable among older adults living in the community. Low rates of diagnosis, barriers to receiving and accepting treatment and other related factors necessitate targeted outreach and unique interventions that address these challenges.

Persons 65 years of age and above comprise only 13 percent of the population, yet account for approximately one-third of all medications prescribed in the United States (National Institute on Drug Abuse, 2010). Older patients are more likely to be prescribed long-term and multiple prescriptions, which could lead to unintentional misuse or abuse. Due to higher rates of co-morbid illnesses, changes in metabolism with age, and potential drug interactions, older adults may experience more severe health consequences as a result of misuse or abuse than younger populations. Illicit drug abuse among older adults is also projected to grow as the baby boomers age (SAMSHA, 2009). According to SAMHSA (2009), those aged 50 to 59 reporting use of illicit drugs within the past year has nearly doubled from 5.1 percent in 2002 to 9.4 percent in 2007 while rates among all other age groups are statistically staying the same or decreasing.

As noted by SAMHSA (2009), “reducing and treating drug use problems among the growing elderly population will require an integrated system of care that combines medical and behavioral health services to fully address the spectrum of problems that patients bring to the primary care setting. Health care providers—particularly those who specialize in treating this population—need to ensure that routine screening for these problems is part of their regular interactions with their patients. Similarly, substance abuse treatment and prevention program managers may wish to consider how they can effectively reach out to and engage older adults with appropriate information and therapeutic modalities”.

SAMHSA’s implementation of ‘Prevention Prepared Communities (PPC)’ appears to be a step in the right direction toward reducing the rate of suicide for American Indians and Alaska Natives (AI/AN). Involving “individuals, families, schools, workplaces, and communities” is an appropriate method of increasing awareness and aiding prevention. Our concern is not with the program’s stated objectives, but the method upon which “effective” practices are constructed. If the PPC program relies solely upon “data driven” or “evidence-based” methods, this could preclude newer, more innovative possibilities that, although in their formative stages, have shown great potential.
The first strategic initiative of SAMHSA acknowledges the place of suicide prevention within the larger context of substance abuse and mental illness. Our concern is with possible limitations in how these programs can be effectively applied to individually diverse communities lacking the administrative capacity to gather the amount of data necessary to achieve statistical significance.
In order to accommodate entities with limited data acquisition abilities in achieving the program priorities, we ask SAMHSA to allow meaningful input by the entities these programs intend to target. The relatively small sample size, by which many communities and villages are characterized, necessitates that measures be taken to incorporate information that goes beyond “numbers”, as measures of success or failure are not determined by a single incident. In this respect, it is imperative for SAMHSA to seek meaningful consultation in PPC formation and maintain a degree of flexibility in its eventual implementation.
Additionally, there is a growing concern among AI/AN Tribes and Tribal organizations regarding SAMHSA’s emphasis on program funding via grants. Although significant measures have been taken to lessen the complexity and administrative burden involved in the grant application process, it invariably forces potential applicants to divert resources that would otherwise be used to provide direct services. The process, inherent to grant applications, requires a specific set of technological and workforce prerequisites that are out-of-reach to many isolated, rural communities – which are often the most vulnerable and in need of assistance.
Beyond the exclusion of those whom the grants are intended to help most, the grant application process invariably puts tribal participants in competition with each other over limited resources. With regard to these practices, we request SAMHSA fully incorporate a distribution and funding system in line with PL 93-638, the Indian Self-Determination and Education Assistance Act, by providing funding through the existing Title I and Title V funding agreements that tribes and tribal organizations have with the Department of Health and Human Services. This practice would allow for the use of a proven effective and efficient Tribal Self-Governance process to further SAMHSA’s mission of substance abuse and mental illness prevention.

Evangelyn "Angel" Dotomain, MBA
President/CEO
Alaska Native Health Board