Year : 2014 | Volume
: 1 | Issue : 1 | Page : 1--5
Future of psychiatry in India: Geriatric psychiatry, a speciality to watch out
Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
|How to cite this article:|
Grover S. Future of psychiatry in India: Geriatric psychiatry, a speciality to watch out
.J Geriatr Ment Health 2014;1:1-5
|How to cite this URL:|
Grover S. Future of psychiatry in India: Geriatric psychiatry, a speciality to watch out
. J Geriatr Ment Health [serial online] 2014 [cited 2020 Feb 26 ];1:1-5
Available from: http://www.jgmh.org/text.asp?2014/1/1/1/141913
India is in a phase of major demographic, economic, technological and social transition. Should we be happy about this changing demographic profile and societal norms? Most of the people would say- absolutely, yes! However, there is a major flip side of the changing demographic and societal norms. The rising elderly population and changing social norms are bringing a new challenge for the economics and health system of the country. This is compounded by the fact that the government is not able to bear the brunt of the pension.  Further, elderly persons also have high morbidity and mortality associated with physical illnesses. All these have important implications on the psychological health of the elderly persons living in this country. If we do not wake up to reality and not take proper initiative at the earliest, we may be heading for a huge crisis.
Therefore, as mental health professions, there is a need to prepare ourselves to care for the elderly in better ways.
Demographics of India: Independence to 2050
Few decades ago health parameters of the country indicated that there was high mortality and high fertility and the life expectancy of an average Indian at the time of independence of the country was merely 32 years.  However, in the last 6 decades or so, the health indices have moved towards lower mortality and relatively low fertility. This change has come about due to the development of various antibiotics and other antimicrobials agents, which have helped in controlling various infectious diseases, and also improvement in the health facilities. The government of India has also focused in reducing maternal mortality, infant mortality and population control. Consequently, one of the major demographic change has been increase in life expectancy. Compared to 32 years in 1947, the life expectancy has continuously increased over the years and it was estimated to be 65 years in 2011.  Due to increase in life expectancy, there is increase in the elderly population. In 1951, subjects with more than 60 years of age formed only 5.5% of the total population, whereas as per the 2011 census this figure was 8.5%. In terms of absolute numbers, those aged more than 60 years were only 20 million in 1951, which has increased by 5 times to 103.2 million as per the 2011 census.  As per the United Nations Population Division,  it is projected that by 2050, the elderly population of India will form 19% of the total population. In terms of absolute numbers, the estimated figure is that of 323 millions, a figure greater than the total population of United States in the year 2012. It is suggested that between the years 2000-2050, the total population of India will increase by 55%, whereas the elderly (>60 years) population will increase by 326% and those with age 80 or more are going to increase by 700%.  United Nations considers a country as 'ageing', when the proportion of people aged more than 60 years reaches 7%. Accordingly, India is considered as an aging nation and in the years to come, we will add more years to life. All this suggests that there is a need for reorientation of mental health services with special focus on the elderly. 
Social Changes: Changing Family Norms and Changing Interaction Patterns
However, this demographic alteration is not occurring in isolation, but is also accompanied by rapid urbanization, influx of technology, globalization and economic change. We are moving from the traditional joint family system in which there were specific gender roles, to nuclear family set up with a competitive family structure in which both the partners are working and have only one to two children.  Traditionally in India, marriage is considered as a universal phenomenon and the matrimony is considered as a sacred Institution which not only binds the two people getting married but also binds the two families. However in recent times, there is alarming increase in the divorce rates.  Even within the families, emotional bonding and communication is reducing due to access to high tech gadgets and preference for communication through social media rather than face to face communication. In other words, it can be said that gradually there is erosion of traditional social norms and the new generation feels more independent in terms of finances and maintaining relationships. From traditional model of inter-dependence we are getting more and more individuated. Resultantly, the elderly are gradually getting marginalized. As people age, because of the nuclear family set-up there are very few people to take care of them. Women in India have been socially and financially dependent on men in their different life phases and they are the most affected by these changing family norms.
Poor Physical Health: A Reality
In terms of physical health, an average elderly Indian is faced with compounded problem of communicable diseases, non-communicable diseases. With increasing age, the immune system weakens and when this is combined with poor living conditions, chances of communicable diseases increase significantly. Studies suggest higher prevalence of diseases like tuberculosis among the elderly compared to the younger individuals. 
There is a rise in non-communicable diseases like diabetes mellitus, hypertension and coronary artery disease. These are associated with long term care and if not managed properly lead to severe impairment in the quality of life and higher mortality. Another major cause of morbidity and mortality in elderly are neoplasms. Data suggests that in this country more than 50% of the elderly aged more than 70 years suffer from one or more chronic physical conditions.  Data also suggests that one-third of mortality among elderly population in India is associated with cardiovascular disorders. Other common causes of mortality among elderly are respiratory disorders (accounting for 10%), infectious diseases including tuberculosis (account for another 10%) and neoplasms (6%).  It is also important to note that these diseases are also associated with significantly high psychological morbidity and cognitive impairment in elderly.  In terms of health care needs, besides long term medical management these illnesses are associated with frequent hospitalizations and costly interventions. However, we all are aware of poor health care infrastructure in this country. Data suggest that more than 90% of the health care expenses are met by people as out of pocket expenses and the government contribution is minimal. When one tries to look at this in the background of poverty and poor living conditions in this country, it can be said that elderly in this country will suffer from huge morbidity associated with both communicable and non-communicable diseases.
Health Care Facilities in This Country: Less Said the Better
We are all aware that health care resources are limited in this country and as discussed earlier, we are cursed with high population. Major proportion of the health care in this country is provided by the private sector which is relatively costly. In terms of facilities for elderly, there are limited numbers of old age homes and are mostly concentrated in the urban areas.  Conversely, major proportion of elderly in India reside in rural areas,  who have no access to these old age homes. These old age homes do not have proper facilities are often overcrowded. Further, these are not free facilities and people who want to live there have to pay for the facility, which makes these out of reach for many elderly.
MENTAL HEALTH ISSUES IN ELDERLY IN INDIA
Epidemiological data about psychological morbidity in the elderly is meagre. Many researchers since early 1970's have tried to study the prevalence of various psychiatric disorders in elderly living in community or in those attending various health care facilities and have come up with varying figures. These studies have been reviewed earlier , and the community based surveys have reported prevalence rates varying from 8.9% to 61.2%, with most studies reporting a prevalence rate of more than 30%. ,,,,, Again data suggests that prevalence of psychiatric morbidity in elderly population living in the community is much higher than non-geriatric population (43.2 % versus 4.7%).  Hospital based studies suggest that elderly form 4.17 to 5.4% of the total outpatients seen in various hospitals.  The most commonly reported mental disorders in community based studies of elderly include depression/mood disorders.  Studies from other settings like old age homes and outpatient clinics also suggest that depression is the most common psychiatric disorder in this group.  The prevalence figures for depression in various studies has varied from 22.2 to 55.2% disability.  Other commonly reported disorders include dementia, anxiety disorders, drug and alcohol abuse, delirium and psychosis. The prevalence rates of dementia have varied from 0.84 to 6.7% and that for anxiety disorders have varied from 5.34 % to 21.35 %.  Studies which have focused on the risk factors for psychiatric morbidity have come up with some important factors like, female gender, low education, being a widow/widower/ divorcee, presence of medical co-morbidities, poor socio-economic status and presence of physical disability. 
Mental Health Services and Training in India: Do These Focus on Elderly
Mental health professionals in India are significantly low when one tries to look at the doctor patient ratio. The same professional caters to children, adults and elderly. In view of this, elderly have to compete with patients of other age groups to get the attention of the busy clinicians. The busy clinicians mainly focus on providing acute care. More often than not, due to pressure of workload, these patients do not receive sufficient attention of the clinicians and resultantly many important mental health issues go un-noticed. Rehabilitation and providing holistic care under one roof has never been a focus of health care planners in this country. In terms of training, geriatric psychiatry does not receive adequate attention during the formative years of post-graduate training and resultantly many psychiatrists do not feel comfortable in managing elderly patients.
As most of the care at the primary care level is provided by physicians than specialists, due to poor exposure to psychiatry during the undergraduate level these physicians are deficient in managing mental health issues in any age group, including elderly.
In a nutshell we can say that geriatric psychiatry services are limited in this country and in terms of manpower, there is no focus on the geriatric psychiatry training. In recent times many initiatives have been taken like having day care centres, old age residential homes, memory clinics, helplines, counselling and recreational facilities but all of these are urban based and concentrated mainly in southern part of India. 
What Should be Done to Address the Needs of Elderly?
Many steps have to be taken to address the needs of the elderly. This involves preventive measures, strengthening the family structure, change in governmental policies in terms of health care facilities and changing the training of postgraduates with a focus on elderly.
There is high physical and psychiatric comorbidity among elderly. Many chronic physical illnesses and resultant disability predispose a person to mental disorders. Therefore, we need to focus on the preventive measures to avoid development of these diseases. In those who have already developed these illnesses, appropriate management must be carried out at the earliest to prevent complications and disability. Hence, large community based awareness campaigns should be launched to make people aware of these non-communicable diseases and the role of early identifications, role of life style factors in development of these illnesses, role of protective factors and appropriate management to reduce complications.
As there are limited resources, we should focus on our strengths. Family and informal caregiving has been one of our strengths. Whatsoever governmental policies may be planned and implemented in this country, it is impossible to plan health care without the involvement of the family. It is important that appropriate measures must be taken to preserve the role of family, may be at the cost of being called backward by a few. Countries from the west are now recognizing the importance of the family and emphasizing the role of family dynamics in the development and management of psychiatric disorders. Unfortunately, we are in the process of discarding our strength. The younger generation needs to understand that post-retirement too, the elderly can contribute a lot to the family and society when given appropriate opportunity. We need to respect our elderly, involve them in family matters so that they do not feel lonely and neglected. 
In terms of financial independence and health care, it is the high time that the Government plans for a sound social security system which will help the elderly to have regular income during the post-retirement years and avail health care facilities without any undue worry about the finances. Some governmental initiatives like - " The Maintenance and Welfare of Parents and Senior Citizen Act, 2007" is a very welcome step and in future there could be a need to formulate more laws to protect the rights of the elderly. Other governmental policies like old age pensions, the National Policy for Older Persons (1999), the National Initiative on Care for the Elderly (2004), and National Programme for the Health Care of the Elderly (2011) are all steps in the right directions. However, there is no evaluation of these policies in terms of actual benefit reaching the needy.
A specific national policy for the geriatric health with special provisions for mental health is very much required. Health care expenditure on the part of the government should be increased with special funds allocated for development of geriatric medicine and other specialities in this country to provide quality services as well as carrying out research in this area. Specialized geriatric centres should be opened in rural areas so as to cater to the majority of the elderly population which resides in the villages and is not able to travel long distances to seek health care.
As majority of the elderly reside in rural areas, we need to strength the skills of the physicians and medical officers in managing geriatric patients. The medical officers should be provided specialized training in the area of geriatric medicine and psychiatry. The primary health care workers like ASHA and other community health volunteers should also be trained to recognise and refer the elderly patients to the health care services for timely management of the ailments.  Most of the hospitals in this country donot have specialized geriatric medicine and psychiatry services. Accordingly, there is need to start the speciality of geriatric medicine and geriatric psychiatry at various premier institutes which can act as training and referral centres. The clinicians should be told that elderly are not a mere extension of adult population and dealing with them requires special skills like patience, thorough evaluation of physical and psychosocial issues, including the issue of nutrition and hygiene. 
In terms of psychogeriatrics, various training centres providing post-graduate training should try to have separate services for the elderly. Depending on the need, as proposed by Tiwari and Pandey,  there is a need to establish state-level Geriatric mental Health Departments. Developing indigenous models which can incorporate traditional methods like yoga, religion and spirituality in prevention and management of various mental disorders is the need of the hour.
Medical Associations including Indian Association of Geriatric Mental Health (IAGMH) have an important role in improving the mental health care for elderly. Associations like ours can act as an advocacy group for the elderly to make the government aware about the priorities for the elderly and implementation of the laid down policies. IAGMH can promote research activities in this area and liaise with other geriatric associations like Geriatric Society of India and Indian Academy of Geriatrics to train the physicians in terms of identifying and managing psychiatric morbidity in elderly. One of the important obligations of associations like IAGMH is to provide a platform to disseminate research in the area of geriatric mental health issues. It is expected that the Journal of Geriatric Mental Health with fill the void in this area and will act as an important resource for the clinicians, researchers and general public at large.
|1||Bhattacharya P. Implications of an Aging Population in India: Challenges and Opportunities. Institute of Chartered Financial Analysts of India. Presented at The Living to 100 and Beyond Symposium. Sponsored by the Society of Actuaries. Orlando, Florida: Society of Actuaries; 2005. p. 1-40.|
|2||Government of India. Situation analysis of the elderly in India. Central Statistics Office, Ministry of Statistics & Programme Implementation. Government of India; 2011.p. 1-50.|
|3||The World Bank, 2011. Country-Wise Data. Available from: http://www.data.worldbank.org/country/india. [Last accessed on 2014 Jun 16].|
|4||Census of India, 2011. Government of India. Ministry of Home Affairs. Office of Registrar General and Census Commissioner, India. Available from: http://www.censusindia.gov.in/. [Last accessed on 2014 Jun 16].|
|5||Department of Economic and Social Affairs. Population Division. World Population Ageing: 1950-2050. United Nations. United Nations, New York: World health Organization; 2002. p. 1-13.|
|6||United Nations Population Division (UN). World Population Prospects: The 2010 Revision. New York: United Nations, 2011. Available from: http://www.esa.un.org/unpd/wpp/index.htm. [Last accessed on 2014 Apr 16].|
|7||Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010;52:113-26.|
|8||Dutt P. The Times of India. Divorce Rates Climbing Up in Bangalore. Available from: http://www.timesofindia.indiatimes.com/life-style/relationships/man-woman/Divorce-rates-climbing-up-in-Bangalore/articleshow/18574314.cms. [Last accessed on 2013 Feb 20].|
|9||Arora VK, Bedi RS. Geriatric Tuberculosis in Himachal Pradesh--a clinico-radiological Profile. J Assoc Physicians India 1989;37:205-7.|
|10||Reddy PH. The health of the aged in India. Health Transit Rev 1996;6(Suppl):233-44.|
|11||Guha R. Morbidity related epidemiological determinants in Indian aged - An overview. In: Ramachandran CR, Shah B, editors. Public Health Implications of Ageing in India. New Delhi: Indian Council of Medical Research; 1994.|
|12||Tiwari SC, Pandey NM. Status and requirements of geriatric mental health services in India: An evidence-based commentary. Indian J Psychiatry 2012;54:8-14.|
|13||Mahajan A, Ray A. The Indian elder: Factors affecting geriatric care in India. Global Journal of Medicine and Public Health 2013;2:1-4. |
|14||Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214-8. |
|15||Shaji KS, Jithu VP, Jyothi KS. Indian research on aging and dementia. Indian J Psychiatry 2010;52(Suppl 1):S148-52.|
|16||Om Prakash, Kukreti P. State of geriatric mental health in India. Curr Transl Geriatr Exp Gerontol Rep 2013;2:1-6.|
|17||Dube KC. A Study of prevalence and biosocial variation in mental illness in a rural and an urban community in Uttar Pradesh - India. Acta Psychiatr Scand 1970;46:327-59.|
|18||Nandi DN, Ajmani S, Ganguli A, Banerjee G, Boral GC, Ghosh A, et al. Psychiatric disorders in a village community in West Bengal. Indian J Psychiatry 1975;17:87.|
|19||Ramchandran V, Menon MS, Ramamurthy B. Psychiatric disorders in subjects over fifty. Indian J Psychiatry 1979;22:193-8.|
|20||Ramachandran V, Menon MS, Ram Murthi B. Family structure and mental illness in old age. Indian J Psychiatry 1981;23:21-6.|
|21||Tiwari SC. Geriatric psychiatric morbidity in rural northern India: Implications for the future. Int Psychogeriatr 2000;12:35-48.|
|22||Rao AV, Madhavan T. Geropsychiatric morbidity survey in a semi-urban area near Madurai. Indian J Psychiatry 1982;24:258-67.|