Old Age Psychiatry: Challenges for the Development of the Specialty
Population ageing associated with increasing mental health needs of older people is a significant challenge for the development of aged care workforces worldwide. The quality and quantity of mental health resources have to be improved to meet the current and future needs.
Despite having very well prepared professionals, a strong evidence base, and an important number of supporters, it is becoming more and more difficult to convince authorities to invest in Old Age Mental Health. Investments in Old Age Mental Health are quite low when we consider the prevalence of mental disorders in old age. The distribution of resources across world regions and income groups is substantially uneven and in many countries resources are extremely scarce.
So, it is very difficult to have a global Mental Health Policy and Programs for Older Persons. In this context, and despite the improvement of educational programs, the recruitment of new human resources to work in Old Age Mental Health is becoming harder. Yet there are huge differences among the world regions in the distribution of the workforce in all health sectors. In Europe we have a mean of 31.8 physicians per 10,000 habitants and 71.3 nurses per 10,000 habitants, in Africa these figures are 2.3 physicians and 12.8 nurses per 10,000 habitants.
Other health professions working with older people are also affected. As noted by Nancy Pachana in an earlier article in this series, lack of geropsychology practitioners within all settings severely limits positive formal contact opportunities for psychologists in training and presents a barrier to the development of positive attitudes towards choosing a career involving work with older adults. A limited geropsychology presence also impacts negatively on availability of supervision and therefore competency acquisition and capability of the non-specialized psychology workforce who will find themselves ever increasingly in contact with older adults.
Lack of resources is not the only factor limiting the recruitment of an adequate health workforce to care for older persons. Ageist attitudes among the general public, policy makers, and health care providers, including physicians, have long conspired to make careers in geriatrics seem to many to be less important and less appealing than other fields.
In an attempt to describe the work patterns of old age psychiatrists in Australia and New Zealand and identify barriers to training and practice, an online survey was conducted of Faculty of Psychiatry of Old Age (FPOA) members from Australia and New Zealand. The majority of respondents practiced in public hospitals. Barriers to private practice included the lack of a multidisciplinary team and remuneration. Very high levels of job satisfaction were recorded (88%) with the main factors being working with older people, working in a multidisciplinary team and the intellectual challenge. The main source of dissatisfaction was bureaucracy. Old age psychiatry is a satisfying career but it may be that the factors associated with job satisfaction give insights into reasons that relatively few psychiatrists choose this career path.
There have been some workforce changes in the past decade. Since 2000, over 100 trainees have completed the Certificate in Advanced Training in Psychiatry of Old Age. Membership of FPOA is increasing in Australia but static in New Zealand. Apart from Tasmania, the number of old age psychiatrists per capita population aged 65 and over has increased in Australia, while in New Zealand it has declined. It has been notable that a number of old age psychiatrists from New Zealand have migrated to Australia and the UK in that period.
In the UK, healthcare is in a state of flux. Services for older people have been criticized as ageist, reinforcing moves towards so-called age-inclusive services, which ignore the specialist needs of older people with multiple comorbidities. The National Dementia Strategy in England has catalyzed some positive changes in terms of dementia services, but these appear to have taken place at the expense of taking the focus away from the complex needs of older people with functional illnesses. These developments are worrying given the increasing population of older people which will inevitably increase the numbers of people needing mental health services in future years. As part of a survey of the work patterns of consultants in old age psychiatry, respondents were asked to specify the things that they find most stressful in their current job and the things that respondents find most supportive. Preliminary results are that lack of resources, management culture and constant change in the system were the most commonly cited stresses. The most commonly cited supports were colleagues. A need for assertive leadership within the specialty was identified, along with a need for old age psychiatrists to link closely with others who have the welfare of older people with mental health problems at heart.
Worldwide, the organization of services is less bright than in the recent past. An increased focus on the service needs of people with dementia and their families has been achieved but perhaps at the expense of older people with other mental health problems. There has been relatively little advocacy for the needs of older people with mood and anxiety disorders, psychotic illnesses and other non-cognitive mental disorders. Consequently it is the responsibility of professionals in old age psychiatry to ensure mental health resources coordination for older persons is achieved equitably so that the needs of those groups of older people without strong advocates are not ignored.
A coordination role may emerge when professionals organize themselves in professional associations to ensure their continuous education and to assume an advocacy role in order to defend professionals’ interests and the interests of those using services. IPA is the leading international association in the field of old age psychiatry, and now includes a group of national associations from 15 different countries. Other associations also can play a important role in this field. The World Psychiatric Association (WPA) has given an important contribution, co-organizing with WHO consensus statements in old age psychiatry and organizing symposia in this field in all its world congresses during the past 30 years. WPA is a federation of national associations from 115 countries.
The World Federation of Neurology (WFN) also is a leading association and offers an important contribution in the field with psychiatrists of neurodegenerative disorders. This federation today includes national associations from 61 countries: in only 8 years WFN has increased its members by 265%.
Finally, the International Association of Geriatrics and Gerontology (IAGG) advocates better health care for older people and has national associations from 104 countries, with an increase of 180% in 8 years.
WPA, WFN and IAGG all have formal contacts with the United Nations and with WHO. This helps to advocate professionals’ interests at the highest level of the development of health policies. It is a pity that professionals working specifically in old age mental health were unable to reach this level. In consequence there are missing opportunities to listen to our voices. One example is the recent UN decision to establish an open-ended working group, open to all States Members of the United Nations and organizations related to the subject, for the purpose of strengthening the protection of the human rights of older persons. This protection of human rights is of high relevance for mental health in old age but there is no representative of professionals working in this specific field in the working group. IAGG has 5 representatives. Why let others advocate our interests?
But not everything is so negative. When the National Institute of Health and Clinical Excellence (NICE) published the draft guidance on the antidementia drugs in the UK, old age psychiatrists knew to react and, in an international and coordinated effort, were able to change what could have been a catastrophic decision. IPA played an important role and organized the IPA consensus meeting and statement on defining and measuring treatment benefits in dementia.
WHO is in the process of revising the 10th International Classification of Diseases and a series of Working and Consultation Groups have been appointed in specific areas. IPA, WPA and the European Psychiatric Association have advocated the creation of a Consultation Group on the Classification of Mental and Behavioural Disorders in Older Adults. This group was formed and the consultation group will focus on mood disorders, psychotic disorders, anxiety disorders and stress-related disorders, personality disorders and substance use disorders.
IPA is playing its role in coordinating old age mental health through Regional Initiative Forums, aiming to encourage development of the field of Old Age Mental Health in all regions of the world. The Regional Initiative program facilitates the sharing of information amongst professionals by providing forums and other opportunities for the exchange of information, identification of issues specific to their region and by facilitating coordination for projects to address these issues. By now there are initiatives active in four regions: Africa, Asia Pacific, Eastern Europe, and Ibero-Latin America.
IPA has also developed Professional Discipline Forums, which provide an opportunity for members of various disciplines with interest in the field to explore mental health and aging issues, from their professional perspective, on a worldwide basis and to identify activities and programs that will benefit themselves, their colleagues, and the communities they serve. Currently, there are activities in the following disciplines: nurses, occupational therapists, primary care physicians, psychologists and social workers.
IPA is keen to address the workforce concerns of all professional old age mental health disciplines, and with its multidisciplinary membership, it is well positioned to coordinate efforts. IPA has established an Old Age Mental Health Workforce Issues Shared Interest Forum to address these concerns as a discussion group within the new IPA Member Forums, accessible through the members’ area of IPA Online. If you are already an IPA member, come and join in the discussion; if you are not, please join IPA and participate in our efforts to address this major global challenge.
We hope that IPA will continue to develop its role of coordination in the field of old age mental health in order to prevent the erosive decimation of our current workforce and collective expertise.
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 was a former member of the IPA Board of Directors.
Brian Draper is a conjoint professor in the School of Psychiatry at the University of New South Wales, Sydney, Australia, the Assistant Director of the Academic Department for Old Age Psychiatry, Prince of Wales Hospital Randwick, Australia and honorary senior research fellow at Neurosciences Research Australia, Randwick, Australia. Dr. Draper is a current member of the IPA Board of Directors, chair of the IPA Shared Interest Member Forum on Behavioral and Psychological Symptoms of Dementia as well as project editor of the IPA Complete Guides to Behavioral and Psychological Symptoms of Dementia.
Susan Mary Benbow is an old age psychiatrist and family therapist who is Professor of Mental Health & Ageing at the Centre for Ageing and Mental Health, Staffordshire University, and Director of Older Mind Matters Ltd (www.oldermindmatters.com). Dr. Benbow is a member of the IPA Expert Advisory Council and a former member of the IPA Board of Directors.
This article is based on the authors’ presentations in the workforce symposium held at the IPA International Meeting in Cairns, Australia, September 7-11, 2012