The Old Age Psychiatry Paradox

The history of Old Age Psychiatry (OAP) starts in the end of the XVIIIth century with the deeper clinical and psychopathological descriptions of mental disorders in older persons and the attempt to build a nosology by medical professionals of this time. The importance of the mental disorders in older persons is proved by the fact that the only mental disorder included at the first version the International Classification of Disease was Senile Debility (Bertillon Classification of Causes of Death – 1893) (1). After the two World Wars the need to care for veterans of both conflicts, and the demographic pressure with the ageing of population emerged the need to develop specific care strategies for this population (2, 3). The recognition of the specificity of (i) the clinical features of mental disorders in old age, (ii) the treatment and care needs of older persons, (iii) their needs for protection against stigma and discrimination, even inside the health and social sectors, have all contributed to the development of what is today called geriatric psychiatry, old age psychiatry, psychiatry of the elderly, psychogeriatrics, etc.

Little by little, obeying much more to local needs than to most noble principles, units and services were created to assume the care of older persons with behavioral disturbances. The pioneers of Old Age Psychiatry came from different horizons (psychiatry, geriatrics, neurology…) and they were dependent on local resources to develop their respective conceptual model of disease understanding and care. Later, they needed to change their experiences, and prepare the future of their activity. This was at the origin of national and international associations. As example at the international level we can mention the European Association of Geriatric Psychiatry which was founded in 1973 and the International Psychogeriatric Association founded in 1982 as the world association of the discipline.

When this generation of pioneers retired at the beginning of the 1990s, their legacy was considerable: a great number of programs, services, educational courses, policies have been developed. The growing number of specialized journals with high quality papers, books, theses published, and communications made in national and international congress testify to the huge interest of the next generations to the topic of old age mental health.

But we are facing a paradoxical situation:  we now have very well prepared professionals, a strong group of knowledge and concepts, and an important number of supporters, including the designation of a WHO Collaborating Center for Psychiatry of the Elderly (4), yet it is becoming more and more difficult to convince authorities to invest in this field. The signs are clear: the recruitment of new human resources are becoming harder besides the increase of the quality of the educational programs and the situation of the organization of services is less bright than in the past (5). This is confirmed by the weaker position today of the geriatric psychiatry services in their respective departments of psychiatry (such as in Germany, Switzerland, New Zealand), by the choice of France to develop a national plan for Dementia without the partnership of national geriatric psychiatrists, the debate at the Royal College of Psychiatrists on the uncertain future of its Faculty of Psychiatry of Old Age, and the present difficulties of the national and international associations to realize with the same periodicity – and with enough number of participants – their respective regular meetings.

The global financial crisis is not a sufficient argument to explain this paradox. WHO and WPA have stated that psychiatry of the elderly is a branch of psychiatry and forms part of the multidisciplinary delivery of mental health care to older people (6). This definition implies two things:

–          psychiatry of the elderly, emerging from psychiatry, is dependent of this specialty concepts, models and methods to understand the origin of mental disorders (bio-psycho-social model) and uses equivalent strategies of care (community based interventions, multidisciplinary, psycho-social rehabilitation model in its large sense);

–          psychiatry of the elderly is only a part of the complex constellation of disciplines interested in mental health care of older persons. Geriatrics, neurology and other medical disciplines advocate the same right which leads to difficulties in the coordination of efforts to improve the better mental health for older persons.

An alternative model of approach is given by the so called ‘geriatric neuropsychiatry’ which is defined as a branch of medicine dealing with mental disorders in old age attributable to diseases of the nervous system. Geriatric neuropsychiatry has become in some countries a growing subspecialty of psychiatry and it is also closely related to the field of behavioral neurology, which is a subspecialty of neurology that addresses clinical problems of cognition and/or behavior caused by brain injury or brain disease. This approach looks somehow reductionist and tends to exclude the non-organic disorders and may give more importance to biology than to psychological and social factors of mental disorders.

Besides huge efforts, OAP has not the status of subspecialty (like Child and Adolescent Psychiatry) in the majority of countries. This is mainly explained by the opposition of other specialties, even among mental health professionals. The choice of those with the responsibility to develop services to care for older persons is much more directed to the offer of the best available care to persons with specific mental health problems such as dementia. This has the advantage of putting together scarce resources but deprives the discipline of its potential to advocate in higher instances better policies, programs and services destined to lead with the full range of mental health problems in old age.

Investments in mental health are still quite few when we consider the huge charge of mental disorders in old age. The new WHO Mental Health Atlas 2011 (7) presents the latest estimate of global mental health resources available to prevent and treat mental disorders and help protect the human rights of people living with these conditions. It indicates they remain inadequate. The distribution of resources across regions and income groups is substantially uneven and in many countries resources are extremely scarce. And the sub-group of older persons is the last to receive these few resources. The fact that OAP failed the role of mental health resources coordination for older persons opens the door for alternative solutions, not always adequate to improve global mental health care.

As in the future the human resources in OAP will not cover the population needs, the following strategies could help to induce necessary changes:

– to include in the plan of action of national and international associations of OAP empowered mental health consumers in order to create a partnership and to ascertain their expectations in terms of a better mental health;

– to develop a deeper partnership with primary care professionals. There is an urgent need to improve these professionals’ skills in diagnosing and managing mental health disorders in older persons as well to develop resources they can call upon;

– to advocate the inclusion of old age mental health issues in all international, national, local policies and to develop evidence based data supporting the availability of better resources and services for older persons with mental disorders.

References

1.  AMERICAN PUBLIC HEALTH ASSOCIATION. The Bertillon Classification of Causes of death. Lansing, Robert Smith Printing Co., State Printers and Binders, 1899.
2. DE MENDONCA LIMA CA, AMENDOEIRA MCR, SCHEINKMAN L, VALLIER E, VASCONCELLOS F. Psiquiatria geriátrica: origens históricas de uma subespecialidade da psiquiatria. Arquivos Brasileiros de Psiquiatria, Neurologia e Medicina Legal 2006; 100 (1): 26-33
3. DE MENDONCA LIMA CA, SCHEINKMAN L, AMENDOEIRA MACR, VALLIER E, VASCONCELLOS F, DA SILVA FILHO JF. Psiquiatria geriátrica: controvérsias em torno de uma subespecialidade da psiquiatria e propostas para resolvê-las. Arquivos Brasileiros de Psiquiatria, Neurologia e Medicina Legal 2006, 100 (2): 17-23.
4. GUSTAFSON L. The 40^th anniversary of the European Association of Geriatric Psychiatry. Aging and Mental Health, 2011; 15 (suppl 1):7
5. LEVY R. What have we learnt in the last 40 years? Aging and Mental Health, 2011; 15 (suppl 1): 6-7.
6. WHO-WPA. Psychiatry of the Elderly: a consensus statement. WHO, Geneva, 1996. WHO/MNH/MND/96.7
7. WHO. Mental Health Atlas 2011. WHO, Geneva, 2011.

Carlos Augusto de Mendonça Lima, M.D., DSci. is the Head of the Department of Psychiatry and Mental Health at Centro Hospitalar do Alto Ave, Guimarães, Portugal. He is a former member of the IPA Board of Directors.