Can geriatric psychiatry services make a difference?

During the past 30 years, the growth of geriatric psychiatry services has been dramatic. Indeed, in this issue of International Psychogeriatrics, Reifler and Cohen report that most developed countries can boast of an impressive range of clinical services that include a variety of hospital-based, community-based, and longterm-care programs. Much of this growth has been fueled by beliefs and rhetoric. Geriatric psychiatrists have rallied to advocate positive attitudes toward the aged, publicize healthcare inequities, and trumpet the development of mental health services for the elderly. Innumerable descriptions of one service or another are testaments to their zeal. Unfortunately, despite the recommendations of a WHO Scientific Group (World Health Organization, 1972), there is little proof that most of these services make any difference. For the moment, the enthusiasm, intuition, and practice styles of geriatric psychiatrists are accepted substitutes for evidence of effectiveness. The best evidence of effectiveness comes from well-designed controlled trials. To date, only 11 trials of geriatric psychiatry diagnostic and treatment services (7 randomized, 4 nonrandomized) have been published in the English or French language literature. Ten have involved systematic detection of depression ( n = 6) , delirium ( n = l), or any mental disorder ( n = 3 ) in hip fracture inpatients ( n = 2), medical-surgical inpatients ( n = l), medical inpatients ( n = l), or aged individuals in residential care ( n = l), home care ( n = 2), primary care (,n = 2), or the community ( n = 1). Systematic detection was followed by consultation alone in three studies, consultation-liaison in three, consultation-nurse intervention in two, or psychogeriatric team intervention in two. The results of these studies were positive in six and negative in four. What can we learn from these studies? On one hand, effective services seem to involve systematic detection followed by consultation-liaison, consultationnurse intervention, or team intervention for depression in home care patients or community subjects; consultation-nurse intervention for delirium in medical inpatients may be effective. On the other hand, ineffective services seem to involve systematic detection followed by consultation alone, particularly in primary care patients. Obviously, relatively few services have been studied. In the future, those services that best manage specific mental disorders in specific types of elderly patients in certain situations and at least cost must be identified by a series of clinical trials. These trials should focus on five issues. First, the need for special geriatric services should