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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 40th
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 currently on the IPA Board
of Directors.
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