Psychiatry at the Helm of the Silver Tsunami

A global phenomenon that is silently but surely establishing its presence is demographic ageing. With a slow yet progressive drop in birth rates across the world, an increase in life expectancy, and a decrease in mortality, population ageing is rapidly changing the demographic scenery in India and across the world. Beginning in high-income countries (like Japan, where over 30% of the population is over the age of 60 years), where it is also known as the Silver Tsunami, it is now gradually affecting the low and middle-income countries.^[1] The proportion of the population ageing over 60 years is projected to increase from 1 billion in 2020 to 1.4 billion in 2030, implying 1 in 6 people will be aged 60 years and above in 2030.^[2] Similarly, the population aged 65 years and above will surpass those 18 years and below by the end of 2070.^[3] India has also expanded exponentially over the last 50 years, with the population aged 60 and above now projected to rise to 19.5% (319 million) of the total population by 2050, from 8.6% in the 2011 Census of India. The proportion of children (aged 14 years and below) in India is projected to decline to 18.5% in 2050 from 37.5% and 34.7% in 1950 and 2000, respectively.^[4] Though there appears to be significant heterogeneity in the population across India, the trend of population ageing has been observed uniformly. This editorial aims to explore the challenges to efficient geriatric mental health and highlight the current strategies of geriatric mental health.

While population ageing could be seen as an insignia of medical and economic advances on the brighter side, it also tips the scales against healthcare for the elderly. Currently available evidence shows that the prevalence of depression could be as high as 30% among the elderly aged 60 and above, along with other mental disorders like dementia and psychosis, which have an overall treatment gap of 83%.^[4,5] Coupled with that are the increasing prevalence of hypertension, diabetes mellitus, and other non-communicable diseases that contribute to higher morbidity and mortality and decreased quality of life in the elderly.

Considering that most geriatric psychiatry patients also have physical comorbidities like diabetes mellitus, hypertension, orthopaedic illness, and other age-related physical disorders, the presentation of clinical symptoms in the geriatric population is often marred by heterogeneity, which brings in a diagnostic dilemma. Some patients may completely deny the presence of mental health problems due to stigma and shame, while others may present with a façade of a multitude of physical symptoms overlying the mental illness.^[6,7] The rise in the number of dementia patients and the presence of behavioural and psychological symptoms caused either by environmental factors or caregiver factors complicates the picture further.^[8] The transition from traditional joint family systems to nuclear families due to urbanisation and migration has led to the collapse of the social support system of the elderly and, consequently, financial insecurity and isolation. This has magnified the geriatric mental health burden.^[9] Low awareness about geriatric mental health and a limited number of only 9000 psychiatrists serving 21 million elderly in India, with 700 psychiatrists joining the fraternity each year, and an equally small number of institutions targeting care for the geriatric population, is undeniably a roadblock in addressing geriatric mental health care.^[10] Meager mental health budgets that are less than 2% of the total budget allocated towards health and disproportionate availability of geriatric services across rural and urban areas are making matters worse.^[11]

To address the grim state of affairs, significant steps have been taken globally and nationally. The World Health Organisation’s (WHO) Global Action Plan on the Public Health Response to Dementia (2017-2025) is noteworthy in its aim towards improvement of the lives of people with dementia, their caregivers, and family members, and reducing the impact of dementia on the community.^[12] The United Nations’ Decade of Healthy Ageing (2021-2030), based on the WHO Global Strategy on Ageing and Health (2016-2030), is a global concerted collaboration targeting the improvement of the lives of older people, their families, and communities. It supports the goals of Agenda 2030 and the 17 Sustainable Development Goals in promoting healthy ageing through integrated health and social care, age-friendly environments with technological aid, and engagement of communities and civil societies in policy and program planning.^[13]

The National Mental Health Program (NMHP) and the District Mental Health Program (DMHP) in India envision quality mental health care services for all through integration of mental health care services with primary healthcare, but specific health services for the elderly are covered patchily.^[14] The National Program for the Healthcare of the Elderly (NPHCE) of 2011 aims at providing easy access to healthcare services, preventive, promotive, and rehabilitative, for the elderly. It also promotes the setting up of daycare centres for the elderly, including those with mental health needs.^[15] The National Policy of Senior Citizens (2011) is also framed along similar lines, with additional focus on elderly insurance schemes and emphasis on early identification of dementia. Despite programs and policies in place, primary care aimed at geriatric mental health still struggles to find its footing in India.^[16]

Meeting the mental healthcare demands of the silver tsunami will need concerted and integrated efforts on a wider scale that percolates down to the primary health care level. Mental health care for the geriatric population requires a multi-disciplinary team-based approach. One study estimated that a total of 7,20,000 beds for geriatric psychiatry patients is required, and against those 7,200 psychiatrists, 7,200 psychologists, and mental health professionals are needed, implying a huge resource and infrastructure deficit in India.^[17] Capacity building and training through integration of competency-based geriatric modules into general psychiatry training, and also upskilling of primary health care workers like medical officers, Community Health Workers, and ANMs, should be focused on.

Beyond infrastructure and resource building, adequate budgetary allocation and proper implementation of programs and policies aimed at the elderly population’s needs should be emphasised. Programs and policies should be planned in accordance with recent research findings so as to be scientifically sound and reap the maximum benefits. Current programs for the elderly, like the NPHCE, could be integrated with mental health programs to fill in the gaps in programs and include health, social security, and financial benefits under one umbrella. At the same time, community care through community-based rehabilitation centres and involvement of local NGOs should be enhanced to ensure equitable distribution of the benefits of ongoing programs and policies. Harnessing the benefits of telepsychiatry and technology like artificial intelligence could accelerate progressive changes in the geriatric mental health system.

Intensive collaborative efforts can help position geriatric mental health at the forefront as the world grapples with an unprecedented demographic change. Communities need to be empowered, our health systems and policies need an overhaul, and only then can the older generations expect to age with dignity for years to come.