The Psychogeriatric Workforce in China: Challenges for the Future
Rapid population aging has brought about great challenges for elderly public health in China. In the past decade, a higher priority has been given to mental health services for the elderly in the public health agenda. However, the resources for mental health service for the elderly are very limited. Much is needed for workforce capacity-building.
In our first national psychogeriatric service survey conducted in 2004, from 28 provinces/major cities, there were only 93 hospitals providing mental health service for the elderly, none of which were officially recognized due to lack of government regulation. The survey found the coverage of inpatient and outpatient care to be very low. Although the Chinese Psychogeriatric Group (CPIG), an Affiliate organization of the International Psychogeriatric Association (IPA), has invested much time and effort to provide training on clinical skills for the diagnosis and management of mental disorders in the elderly, geriatric psychiatry has yet to be officially recognized as a subspecialty in China.
There remains a great gap in service demand and provision. A demonstration subspecialty training program will be implemented by the Peking University Institute of Mental Health within the next 3-5 years. The demonstration program is designed to train geriatric psychiatrists, who have completed instruction in general psychiatry, providing them one-year of clinical training in outpatient, inpatient and community outreach services, and six-months of research training, in addition to didactic training on topics relevant to Psychogeriatrics.
With increasing awareness of mental health issues, the role of general practitioners in the management of mental health problems has become more and more important. Elderly with mental health problems mostly prefer to seek medical care in general hospitals. This could be partially attributed to the limited resources of specialty mental health services, as most mental health services are located in psychiatric hospitals that are separate from general hospitals.
But in psychiatric hospitals, the doctors are often not adequately trained to manage physical health problems. When an older person in a psychiatric hospital suffers a noticeable physical difficulty, he/she will be referred to a general hospital for further diagnosis and management. The concern over the potential psychological problems caused by physical diseases may also be accountable for this care-seeking preference. However, mental health problems among the elderly may be masked by the physical conditions and impact of social and family roles, and thus be neglected by the older person, the family, and even their physicians. On the other hand, general practitioners may pay more attention to the biological causes of the physical complaints.
The symptoms of mental health problems may be under-recognized or missed when the awareness of health professionals is relatively low. Mental health services may not be considered mainstream in general hospitals and thus fewer physicians are willing to be specialized in it. However, as suggested in the national mental health plan, the rate of detection and treatment of depression in general hospitals should be increased by 60% in the next 5 years. How can this be achieved? Providing training on clinical skills to recognize mental health problems, and establishing the liaison and referral system between general practice and mental health specialized departments or hospitals are among the possible solutions.
In addition, the number of psychogeriatric nurses in China is very limited, and very few are formally trained. No national data regarding psychogeriatric nurses is available. In a survey on psychiatric nursing service resources conducted in 2010 in Beijing, approximately 10-15% of the respondents in psychiatric institutions practiced care for the elderly. Most of the nurses received about three years of formal college education, with training in geriatric nursing of only about 20-30 hours. The continuing medical education (CME) program is the primary career training for nurses caring for the elderly. Specific skill training is implemented and integrated during their routine clinical practice.
There are many challenges for psychogeriatric nurse capacity-building. Specific training is urgently required including the recognition of mental health problems, health education, group intervention, long-term care, and support for home care.
The resources of psychologists and social workers on psychogeriatric services are even poorer in China. A few non-government organizations (NGOs) are now working in the community to provide psychological support and consultation for the elderly. However, their services are not well regulated and professional service skill training is insufficient. As community and home-care for the elderly is encouraged by the government and there may be increased investment in the primary care system in the coming decade, it would be feasible to develop the community-based service workforce in China. For example, community doctors, nurses and even staff in NGOs could be considered the major service providers. Developing a curriculum on the practice skills, and providing regular supervision would be more practical for building a culturally appropriate community mental health service team in China. Meanwhile, the cost-effectiveness of this approach should be evaluated during the implementation.
In summary, the psychogeriatric workforce in China needs improvement to meet the demand for better mental health well-being among the elderly. We expect that workforce capacity-building would be enhanced through sharing with, and learning from, our international colleagues.
Huali Wang (current member of the IPA Board of Directors), Hengge Xie, Li Ma, Xin Yu
Psychogeriatric Interest Group, Chinese Society for Psychiatry