IPA Bulletin
Around the World

PSYCHOGERIATRICS IN KOREA
How Korea Is Meeting the Challenge of a Rapidly Aging Population

BY GUK-HEE SUH

Korea is rapidly aging, but is not being prepared for an upcoming tide of ageing. Both the number and the proportion of the elderly with mental disorder will increase substantially. It is only in last decade that more systemic development of psychogeriatric services has begun under the pressure of rapid aging. This article describes the various stages of development of psychogeriatrics in Korea. The Korean model of service delivery can serve as an example of development of psychogeriatric services for developing countries.

Introduction

Korea is located in the middle of China and Japan. The population is now 48 million without ethnic diversity. The proportion of people aged 65 and over was 7.4% in 2001 (Korea National Statistics Office, 2002). The last several decades have witnessed rapid global demographic transition. Declining fertility and mortality rate has had a major impact on the structural aging of Korean society. As a result, the proportion of the population under 15 years of age is decreasing, while that of the population aged 65 and over is increasing. The utmost challenge for Korea is its exceptionally rapidly aging population. Life expectancy at birth was 75.9 years; 72.1 years for males and 79.5 years for females in 2000. Proportion of the aged 65 and over will double within 20 years, 7.3% in 2000 and 15.1% in 2020 (Korea National Statistics Office, 2002).

The main challenge in rapid aging is the exponential rise in the ‘old-old’ population. Most elderly aged over 85 have several comorbid chronic diseases and need assistance in daily living. Unmet need of the elderly is a great sociomedical task.

To meet these growing needs, rapid development of psychogeriatric services in Korea has taken place since the early 1990s. Geriatric psychiatry has been widely recognized as a subspecialty of psychiatry in Korea since 1994, when the Korean Association for Geriatric Psychiatry (KAGP) was founded. Government enacted the Mental Health Act in December, 1995. KAGP, now with more than 250 members, also has grown up enough to host the 2004 Asia Pacific Regional Meeting of International Psychogeriatric Association (IPA). This article reports on the development of geriatric psychiatry in Korea with reference to social security network and medico-social system.

Social Security Network in Korea

Over forty percent of the total Korean population (20 million in number) lives in Seoul and its vicinity. Korea is highly urbanized and modernized. There are local governments of seven metropolitan cities and nine provinces, as well as central government. Though it has a progressive income taxation system, the basic health needs of the population are covered by universal public health insurance funded by premiums, not by taxes. There is no private health insurance but a compulsory public one. There are parallel health care systems for the poor and aged. Central government is responsible for free nationwide health care funded by taxes. Korea also has social service provision for the unemployed, disabled and aged.

There are five main programs for Korean Medico-Social Service for the elderly: income support, elderly job placement service, housing programs for the elderly, leisure activity programs and long-term care programs. And there are four public pension programs in Korea: national pension (NP), Government Employees Pension (GEP), Military Service Pension (MSP), and Private School Teachers Pension (PSTP). The GEP, MSP and PSTP are for those who have been employed in specific job areas such as government, military service sectors and private schools. About four percent of the elderly aged 60 years and older were receiving the old age benefits under the public pension programs in 1995. The national Pension Program provides cash payment to retirees and covers most adult Koreans. It started in 1988; therefore, the majority of older Koreans living today are not eligible for the pension benefits because of the minimum 15-year contribution requirement.

Two programs are available for the needy aged under public assistance:

The Livelihood Protection Program.
This is a restricted public provision for the low-income elderly, below the poverty level, aged 65 and over, with no legal supporters. The benefits provided to the recipients under the livelihood protection program include medical aids, provision of tuition for children in school, funeral assistance and relief aids. The amount of cash benefits per month come from the relief aids, medical aids, and so on. Monthly domiciliary protection benefits are 162,000 Korean won (US $203) and monthly institutional protection benefits are 125,000 Korean won (US $156 ) in 1998.

The Old Age Allowance Program.
This is a monthly cash payment mechanism to the needy older Koreans aged 65 and over. To be eligible for it, the elderly had to be below the poverty level and older than 70 in 1997. The age lowered to 65 in 1998. Between 50,000 and 40,000 Korean won are provided monthly for the elderly aged 65 and over.

Korean society has experienced dramatic changes in the process of industrialization and modernization since the early 1960s. Elderly Koreans had spent their lifelong earnings in order to raise and educate their children. After launching their children, they were left poor. In spite of their poverty, the government failed to provide support for them via appropriate policies until late 1980s. The national pension program has been implemented only in 1988. The Korean government provides the cost of living and medical care assistance for the elderly in community and for the institutionalized elderly as a public assistance program. Cost of living is not provided for the selfsupporting elderly but benefit for medical care is given. Livelihood protection allowance reached the minimum cost of living in the year 2000. Medical insurance is provided to all the Korean population without exception.

Development of Psychogeriatric Services

Thanks to the community mental health movement in the public and private sectors of psychiatry, nationwide 242 health centers have formally begun to register and take care of the frail elderly, especially those with dementia or stroke since 1995. In 2002, there exists 989 mental health related facilities in Korea, including 46 community mental health centers, 66 social rehabilitation facilities, 74 mental hospitals, 207 general hospitals with psychiatric outpatients, 541 psychiatric clinics and 55 nursing homes. Additionally, 35 new mental hospitals for the elderly under the support of government funding will open sooner or later. Home and institutional care programs are given for long-term care. Home help service and delivered meals, adult day care, short stay and respite care and visiting nursing programs have helped the elderly with disabilities and its number has been substantially increasing to address the unmet needs. To meet the need for institutional care due to increasing cases of dementia and stroke, special units in nursing homes and dementia care hospitals have been constructed throughout Korea. A multidisciplinary community- oriented approach was adopted and a close working relationship has been maintained with various professionals for care of the elderly. However, the number of mental health care facilities does not meet the need.

Though the estimated number of the elderly with dementia was about 280,000 in 2001, only 1,806 out of 5,586 nationwide registered patients with dementia were admitted or institutionalized, according to national health statistics. Most of them were taken care of in the community by family members. Several kinds of service models exist to care for the elderly, such as community health centers, day care centers and social rehabilitation facilities. In general, each team has a catchment area of about 50,000 – 200,000, including 3,500 – 14,000 aged 65 and over. The staff usually consists of one consultant psychiatrist (rarely a full-time psychiatrist), one community psychiatric nurse, one social worker or psychologist and several volunteers. They complete community resources for the most effective care to help the elderly to stay longer in their own homes. They have responsibility for registration, case management and education. Some run day care programs for dementia. The public sector has been more active in homevisiting outreach activities, while the private sector has been focused on day care activity with rehabilitation. These active movements have been helpful in developing the infrastructure for psychogeriatric service delivery.

Epidemiological Issues and Needs for Service

There have been several communitybased epidemiological studies on the prevalence of mental disorder in the Korean elderly (Lee et al., 2002; Suh & Shah, 2001; Woo et al., 1998). Epidemiological data on the prevalence of mental health problems in the elderly are important to evaluate the need for services.

Dementia and depression are most common and the most severe public health problem. Korean reports have been comparable to those of western studies. Suh et al interviewed 1,037 elderly aged 65 and older and found a prevalence of dementia of 6.8%, Alzheimer’s disease 4.2% and vascular dementia 2.4% (Suh & Shah, 2001). Lee et al examined 653 elderly aged 65 and older and found a prevalence of dementia of 5.3% (Alzheimer’s disease 4.3%)(Lee et al., 2002). A nationwide survey examined the prevalence of depressive symptoms in the elderly in Korea. It found a prevalence of 25.4% using a cutoff score of 16/17 in CES-D (Center for Epidemiologic Study of Depression) (Cho et al, 1998; Suh et al., 1999). A community-based survey reports a prevalence of a wish to die in the elderly of 14.6% within the last two weeks (Suh et al., 1999).

A total of 788,000 people—equivalent to 21% of Korean elderly,—needed long-term care in 2001. At least 74,000 people needed institutional care, while the remaining 714,000 needed community care. The number of dementia patients with disturbed activities of daily living was 186,000. They will seek institutional care sooner or later. (Sunwoo D, 2001).

Problems and Budding Hope

There are several problems. Medical, psychiatric and social welfare services are separated, so needs are not addressed simultaneously. This separation originated from artificial distinction between treatment and care. Second, subacute care facilities are too scarce. There are only acute and chronic care facilities. A differentiation of function in facilities is necessary, for example a hostel for mild cases and a nursing home for severe cases. Third, public care facilities are too few (less than 10%). Most facilities are private, leading to frequent conflict between consumers, government and suppliers. Fourth, the elderly care facilities are deficient and not specialized. Even unauthorized freestanding care facilities take a role as institutions. Fifth, government does not go much beyond a “family support first, public support next” policy. However, the Korean government has increased the expenditure for elderly medical care and social welfare to meet the unmet needs of the elderly, though not sufficiently. In addition, the government it is considering adopting of a long-term care insurance system, similar to what has been available in Germany and Japan. National pension benefits will be available for the elderly in 2003, which will greatly improve quality of life for Korean elderly. In addition, Korean people’s awareness of the upcoming variety of problems from rapid aging has greatly improved. They are more encouraged to keep money for their own old age and to raise NGO movement to ask policy-makers to provide greater support of the elderly.

Conclusion

Korea is rapidly aging, but is not being prepared for the upcoming tide of aging. Both the number and the proportion of the elderly with mental disorders will increase substantially. Therefore, health policies to meet the unmet needs of the elderly Korean population are urgently needed.

COMMUNITY SERVICES FOR THE ELDERLY IN KOREA YEAR 2001
Total population.....................................................................................48 million
Number (percent) of the elderly aged 65 and older....................3.6 million(7.4%)
Residential Services (old age homes, nursing homes) ...................................225
Home Help Services .......................................................................................113
Meals-on-Wheels............................................................................................113
Community Psychiatric Nurses.....................................................................1,892
Day Care Centers.............................................................................................82
Board-certified Psychiatrists ........................................................................1,850
Members, Korean Association for Geriatric Psychiatry.....................................250
Specialization in other professions in the multidisciplinary team ....................yes
Systemic teaching of psychogeriatrics in undergraduate curriculum ...............yes

REFERENCES

Cho, M.J., Nam, J.J. & Suh, G.H. (1998). Prevalence of Symptoms of Depression in a Nationwide Sample of Korean Adults. PSYCHIATRY RES. 81, 341-352.

Korea National Statistics Office. (2002). STATISTICAL ANNUAL 2001. Daejeon, Korea, Korea National Statistics Office. 

Lee, D.Y., Lee, J.H., Ju, Y.S., Lee, K.U., Kim, K.W., Jhoo, J.H., Yoon, J.C., Ha,J. & Woo, J.I. (2002). 
The Prevalence of Dementia in Older People in an Urban Population of Korea: The Seoul Study. J. Am. GERIATR. SOC. 50, 1233-1239. 

Suh, G.H., Cho, D.Y., Rhoo, I.K., Yeon B.K., Choi, I.G. & Cho, M.J. (1999). Prevalence and Risk Factors of Depressive Symptomatology Among the Korean Elderly. JOURNAL OF THE KOREAN GERIATRICS SOCIETY 2(1), 49-60.

Suh,G.H., Kim,J.K., Jung,Y.J., Kim,M.J. & Cho,M.J.(1999). Wish to Die and Associated Factors in the Rural Elderly. JOURNAL OF KOREAN GERIATRIC PSYCHIATRY 3(1), 70-77.

Suh,G.H. & Shah, A. (2001). Review of the Epidemiological Transition in Dementia—Cross-national Comparisons of the Indices Related to Alzheimer’s Disease and Vascular Dementia. ACTA PSYCHIATR. SCAND. 104, 4-11.

Sunwoo D. (2001). Survey of the Long-term Care Service Needs of Old Persons and Policy Direction. Seoul, Korean Institute for Health and Social Affairs. 

Woo, J.I., Lee J.H., Yoo, K.Y., Kim, C.Y., Kim, Y.I. & Shin, Y.S. (1998). Prevalence Estimation of Dementia in a Rural Area of Korea. J. AM. GERIATR. SOC. 46, 983-987.

Guk-Hee Suh, M.D. PhD, is an Associate Professor of the Department of Psychiatry, Hallym University College of Medicine and associate editor on International Psychogeriatrics. He can be reached at suhgh@chollian.net.

Reprinted from IPA Bulletin Volume 20 Number 1