The guest of honor and her two friends were beaming when Dr. Marc E. Agronin, a geriatric psychiatrist and the director of mental health, arrived with a hug for everyone long after what would be normal office hours.
The Merry Widows moved to the community when their husbands developed Alzheimer's disease and looked to Dr. Agronin to prepare them for what lay ahead. But while treating their husbands' disease, he became their psychiatrist, too. He urged the women to attend therapy groups, made suggestions about medication for anxiety and encouraged new bonds of friendship.
Dr. Agronin calls them his graduates — a trio of success stories among 3,700 patients he is responsible for, in what, by all accounts, is the largest geriatric psychiatry practice in the nation, at the Miami Jewish Health Systems.
The doctor is a rare breed even in Florida, which has the highest proportion of people older than 65. There are only 17 board-certified geriatric psychiatrists in the state, and a mere six here in southeast Florida, where snowbirds from New York often come to perch. In March, acknowledging the crisis in care, the federal Institute of Medicine began a study of the shortage of geriatric mental health workers nationwide.
Dr. Agronin, 45, is unusual not just because of his specialty but because he is a salaried staff member immersed in the fabric of life for patients and caregivers. Residents in most senior facilities must await a shifting cast of mental health professionals, who are available — even for a prescription — only one or two days a week or in an emergency.
Now, a growing number of experts are calling for integrating mental health professionals into all levels of communities for the rising population of aging Americans, from nursing homes to assisted-living centers.
Gary Kennedy, the director of geriatric psychiatry at Montefiore Medical Center in the Bronx, says psychological care is "equally if not more important than" medical care for this group. "Health policy continues to lag behind the reality that these are now mental health facilities," Dr. Kennedy said of communities for the elderly.
While Alzheimer's receives the lion's share of public attention, garden-variety depression, anxiety and sleep disorders also accompany old age. Particularly for late-life depression, Dr. Agronin points to data assembled by the psychiatry department at the University of California, San Francisco, supporting behavioral and group therapy, treatment rarely tried with patients from generations typically considered averse to discussing such issues.
But treatment that focuses on talking, rather than on medical procedures, has a lower Medicare reimbursement rate. The economic difficulties may explain why more doctors have not entered the time-intensive field.
"Approximating what I do is hardly economically feasible," said Dr. Agronin, the author of "How We Age." "Caregivers need assessment and services as well, and this is not reimbursable time."
For Dr. Agronin, and for the social worker and the psychologist who work with him, there is no such thing as the 50-minute billing hour. Rather, on a routine day, his work is often done ad hoc as he wanders the corridors, dining rooms and garden here. He loosens the boundaries set by most schools of psychiatry, which discourage clinicians from befriending patients. Here, staff members are physically affectionate and may even give patients a personal cellphone number.
"He is a lifesaver," Mrs. Weisburd said as Dr. Agronin helped blow out the candles on her cake. "He helps you walk down the mountain."
The mountain is old age, with its physical and cognitive decline, its steady loss of loved ones and its inevitable outcome. Dr. Agronin says his mission is to restore dignity and hope to people who were raised at a time when mental issues were often stigmatized.
Some 700 of Dr. Agronin's patients live on the main campus of Miami Jewish Health Systems, in independent or assisted-living apartments, a nursing home or an Alzheimer's unit. The rest of them come to his clinic or are served by the system's community programs throughout South Florida.
Dr. Agronin and other geriatricians find that behavioral therapy (changing the way one thinks and solving current problems) works better than analysis (excavating the past). And Dr. Agronin, who has written about some of his cases for the Science section of The New York Times, said he relied on group therapy because patients often benefit from the insights of their peers.
That was the case with Francoise Dorville, a 78-year-old Haitian immigrant who uses a wheelchair and is on dialysis and oxygen. Mr. Dorville, a widower estranged from his four surviving children, was stabilized with medication for depression and then agreed — reluctantly — to participate in a group.
Though he did not make eye contact with anyone in the group for the first month, Mr. Dorville did show up for the daily two-hour sessions. Eventually, the group persuaded him to contact his children, discussing his old-country idea that being a good father meant providing food and shelter and little else.
Mr. Dorville told his children that he would welcome a chance to be a more loving parent. Now they visit regularly; one son brings dinner weekly, and a daughter-in-law assembled a family photo album. Mr. Dorville describes himself as "a happy man."
Dr. Agronin said that older people were not by definition miserable. "We have to be very careful in the assumptions we make," he said, "and not project our own fears of aging. Their lives can be way better than we imagine."
The Merry Widows — Mrs. Weisburd, Muriel Cohen, 91, and Sandra Sachs, 78 — made their way here by a common route: from homes at the edge of golf courses. Wives and mothers for 50-plus years, they arrived with their husbands but remained here after their deaths.
"It's like being on a cruise," Mrs. Weisburd said. "You don't have to change the sheets, and there's always something to do."
Dr. Agronin sees them daily as they hurry between knitting classes and lectures on current events. Recently, he wandered into the library where they were chatting. Out of the blue, the usually buoyant Mrs. Weisburd lost her composure. Two of their regular dinner companions had recently died, she told him, breaching a dam of tears.
Mrs. Cohen added, "I cried so bitterly — more than I did for my husband."
Why, Mrs. Sachs asked, "do they send buses of psychologists to a high school every time there's a tragedy," but here, where death is constant, "there's only a brief memorial service and cookies?"
Dr. Agronin talked to them about accumulated grief, how one death re-opens others, how they had held themselves together for their families' sake. He said grief is part of the human condition, not a psychiatric problem.
"You are doing exactly what you should be doing: talking to other people," he reassured them. "But maybe we need to do that more deliberately."
So a new therapy group was born.
http://www.nytimes.com/2011/05/01/us/01elderly.html?src=recg&pagewanted=all
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