As Sri Lanka’s ageing population continues to soar, the psychiatric morbidity of our elders has seen a visible spurt, a view endorsed by the World Health Organisation (WHO), the UN and a number of cross sectional studies carried out by private individuals and hospitals. These surveys are important since the country still lacks a proper mental health index which is an important indicator of the overall well being of a growing aging population.
While recent events, such as, the effects of the conflict and the tsunami have aggravated the burden of psychological problems among the elderly, alcohol and substance use are also on the rise, especially, in elderly persons with low levels of education and physical disabilities. A 2010 study showed elderly persons were at higher risk of Depression, Dementia and Cognitive dysfunction than younger people. Studies have also shown that while many progressive interventional steps are now in place by the Ministry of Health, lack of resources and staff are problems to be reckoned with.
With the International Day for Elders being observed on October 1 the Sunday Observer asked Senior Consultant Psychiatrist and a Founder Director of the National Mental Health Institute, Dr Jayan Mendis how these challenges could be resolved.
Excerpts…
Q.Mental health of the elderly has received strong focus since the WHO landmark report ‘Bridging the Gap’ which gave priority, regionally and globally, to including it as part of its Sustainable Development Goal (SDG) agenda for 2020. According to it 322 million across the globe suffer from depression which is the leading illness in the elderly. What is the situation in Sri Lanka?
A. The elderly population in Sri Lanka has grown rapidly in the past few decades. It was only about 2.5 million in 2012. However, now this figure has reached 4 million or more. In addition, in Sri Lanka, the oldest age category (75+) is increasing more than the young, (60-74 age group). Further, the ageing process shows a rising number of women in the older age group than the number of men. The number of widows is likely to increase in the future and expected to live longer, which is already happening in Sri Lanka . When they live longer they have more physical, physiological, social and other problems relating to age. Of these, pyscho-social issues would be greater in Sri Lanka than in most other Asian countries. Our families are now becoming more nuclear ,and strong family links are disappearing, with some family members migrating overseas. This has resulted in parents living in their houses alone. All this has contributed to various psycho-social issues, like stress reactions, depressive disorder, delusional disorders and various types of dementia.
What are the signs of depression in the elderly?
Some disorders are more prevalent among men, such as, substance and alcohol use disorders, personality disorders and dementia. However, depressive disorders are commoner among females. Due to increased longevity in females, they are more prone to disorders such as, depressive disorder, which is not a normal part of normal ageing. It is a disorder of mood.
Q. What are the early and potential triggers that cause them in elderly persons?
A. Some elders are prone to develop depressive disorders, especially, those who have had depression in the past or those who have genetic proneness. Common signs and symptoms are sadness or feeling of despair, unexplained aches and pains, loss of interest in usual hobbies, weight loss and/or loss of appetite, feeling of hopelessness or lack of motivation.They also lose work concentration, which may mimic memory dysfunction.They commonly have worries about being a burden. Thoughts of suicide are seen in a severe form. Some may even attempt to commit suicide or may even commit suicide.
Q. Apart from Depression, what are the other leading causes of mental illness in Sri Lanka? Anxiety , Dementia, Alzheimers? A survey showed that 40% of elderly patients admitted to the National Hospital suffered from Depression.
A. You will see various kinds of worries, especially, when they have suspicions and worries about either of their spouse or about the neighbours. This could be the presentation of delusional disorder. Dementia sometimes presents depressive symptoms or of being suspicious. All these disorders are commonly seen in the elderly.
Q. Can chronic non communicable diseases be linked to mental illness? Some hospital surveys in Sri Lanka have shown evidence that diabetes, heart problems hypertension, cognitive dysfunction were also significant contributors to mental disorders among the elderly. Your comments.
A. Smoking and hypertension, fatty diet, vitamin deficiencies, diabetes, obesity and various forms of heart diseases and chronic kidney diseases are common non communicable diseases in Sri Lanka. All these can produce various forms of psychiatric disorders, particularly, dementia.
Q.What are the emerging challenges you see in mental health ? What kind of gaps are there at present to meet these challenges?
A. At present we have enough specialists to provide services to adults. However, specialties such as child, elderly and forensic, lack manpower resources. We have some trained medical officers, but we require about 300 well trained medical officers for mental health to provide a better service. There is also a shortage of psychologists and other multi-disciplinary team members.
Q. Any other challenges?
A. There is a strong stigma attached to mental health disorder. As a result still people do not like to come for treatment and try to hide their disorders. The district development of mental health service is not uniform. Some basic facilities such as, the acute psychiatric unit, intermediate rehabilitation unit, long term rehabilitation unit, emergency care management are not always available.
The emergency psychiatric care management is also not happening in a smooth manner. Free ambulance service facility is not available for those with psychiatric disorder. Community mental health programmes need further sophistication in most districts. There has to be a proper follow up mechanism for patients, which is now haphazard.
Q. The initial Mental Health Policy for Sri Lanka for 2005-2015 is now being revised from 2015-2020 with many initiatives and services being provided. What are these interventions?
A. The Mental Health Policy came into effect in 2005. Before that we did not have a mental health policy. We had a few regional centres and the large Mental Hospital in Angoda before 2002.
After 2005 we concentrated mainly to stabilize the district mental health service. It mainly had the provision of mental health services at primary, secondary and tertiary level, to provide quality services where and when needed; to organize services at the community level with the involvement of community, family and consumer participation; and to link the services to other sectors and provide the rights of the mentally ill as they were neglected at that time. I am happy that we could achieve a lot from the Mental Health Policy 2005.
In addition, we have introduced 15 main objectives, strengthening of the leadership with a good governance at national, provincial and district level. We have also concentrated on the provision of fully specialized services, such as, child, elderly and forensic services at district level. We have concentrated on the reduction of suicide and deliberate self- harm. These are some of the new policy considerations, but all stakeholders have not finalized the policy yet, which we are going to do soon.
Q.Sri Lanka still has only one state hospital designated for mental health services - the National Institute of Mental Health ( NIMH) of which you were a founder member. Is this a drawback or are there now services in this area in other state hospitals?
A. It is not a drawback. I, as Founder Director, gave leadership to organize the then mental hospital to a somewhat decent mental health care provision institution for the country .We have converted it to a mental health training centre with accommodation facilities. Any staff member coming to the Institute from any part of the country can obtain training in the area of mental health. It is the duty of the new administration to take the Institute to a different level according to the new Mental Health Policy vision. It is also the duty of the Institute to train multi-disciplinary staff required for the whole country in a methodical manner. In addition to the NIMH almost all the districts now have a psychiatric unit headed by at least one psychiatrist. Their quality needs to be improved in a planned manner.
Q. Does taking care of the mentally disturbed elderly require a multi-disciplinary team effort? If so who should comprise this team?
A.This could be done in different ways. One by a general adult psychiatrist with his multi-disciplinary team members such as, mental health trained nurses, occupational trained members, occupational therapist and if possible psychologists trained in neuro-psychiatrists.
The different members of the team have different job specialties and abilities to provide different kinds of services.
Q.The trend now is to de- institutionalize elderly care and encourage more families to take the responsibility of looking after their parents. Do you think this is a good thing? Can they manage such patients if they need special care following a stroke or heart attack?
A. Yes, for any person, his own house and family is the best place of treatment. But as I have explained earlier, there are psycho-social changes that have occurred in Sri Lanka.
As a result home care treatment may not be an option where we need to have properly trained carers to look after the elderly in their own homes. We need to plan and have these carers ready by now, if we are to keep our elders at home.
Q.Your message for October 1?
A. Cherish your parents and elders and ensure that they enjoy a quality life of longevity.