Geriatric Depression: Challenges in India
Mental and behavioural disorders are estimated to account for 12% of the global burden of disease which affects approximately 450 million people. Depression is undertreated in the elderly, and perhaps particularly so because it is not yet perceived as a priority public health problem in developing countries. WHO reports, patients over 55 years with depression have a four times higher death rate than those without depression. The contribution of depressive disorders to suicide is widely recognised. Geriatric depression is both a disease and a risk factor of other related diseases.
Geriatric mental health is plagued by many challenges that prevent the development and progress of its services. Lack of trained professionals, scarce geriatric mental health infrastructure, and a dearth of financial resources for geriatric mental health are some of the challenges that our nation faces. Geriatric mental health problems can be accurately diagnosed and effectively treated if help is sought early, but it is largely assumed that they are part of normal ageing. Women, particularly in old age, are more prone to social insecurity, health problems, and greater emotional or financial insecurities and thus to more mental health-related problems.
Issues of comorbidity:
A key clinical issue in geriatric mental health is the heterogeneity in clinical presentations that confounds diagnosis and treatment of these problems. Patients usually deny the presence of mental health problems and are reluctant to seek help. Physical symptoms may be the chief complaint in many cases and the underlying psychological problems obscured. There are incomplete clinical pictures where diagnostic criteria are not satisfied, but the problems are severe enough to warrant treatment. Patients differ in the degree of mobility they possess as some may be bedridden and malnourished, some may be wheelchair-bound, and others are ambulatory. Clinical heterogeneity in presentation, varying symptoms, presence of medical illnesses, multiple disorders, medications, and being treated by multiple doctors make geriatric mental health more challenging.
Caregiver strain:
The changing family value system, economic compulsions of children, neglect, and abuse has caused elders to fall through the net of family care. Homes for the aged are ideal for elderly people who are alone and face health problems, depression, and loneliness. India has four types of resources to address geriatric mental health issues, namely- state-funded government psychiatric hospitals and nursing homes, private psychiatric hospitals and nursing homes, nongovernmental organizations (NGOs), and, most importantly informal sources i.e., family as caregivers. Geriatric patients suffering from prolonged mental disorders that severely decrease their functioning capacity, especially with disorders that are accompanied by psychosis which requires constant observation and care. Due to this increased responsibility, a greater caregiver strain has been reported with patients with greater psychotic symptoms.
Muted psychiatric care in primary settings:
The lack of awareness regarding geriatric mental health care at a primary care level poses another challenge. In India, elderly people living in nursing homes and old-age homes are usually in a state of mediocrity until it is an extremely well-paid setting. These homes do not have a psychiatrist or psychologist for their residents. The primary health-care physicians, most often, are not separately trained to identify and treat psychiatric issues such as dementia or depression in the elderly.
Although new initiatives such as day-care centres, old-age residential homes, memory clinics, helplines, counselling, and recreational facilities are being developed, most of them are urban-based and concentrated mainly in the southern part of India. NGOs such as HelpAge India, the Agewell Foundation, and the Dignity Foundation too are active contributors, but still, efforts are far from reaching the masses.
Lack of Indian diagnostic tools:
The preexisting diagnostic tools and criteria do not adequately assess the mental health status of older people leading to a misdiagnosis or passing out the net of diagnosis. As such, the varying manifestations due to cultural strains might get dissolved.
The clinical challenges:
Depression is undertreated among the elderly. The psychosocial factors associated with geriatric depression are female sex, widowed status, nuclear families, and stressful life events. Older adults are likely to suffer from subsyndromal depression, i.e., depression that does not always meet the full criteria for major depression but can lead to major depression if left undiagnosed or untreated. Geriatric depression reduces the quality of life and increases the risk of suicide in the elderly.
Demographic factors associated with depression are factors such as residing in rural areas, illiteracy, lower socioeconomic status, and unemployment. There is no single cause of geriatric depression, and multiple factors at biological, social, and psychological levels interact to cause depression in old age.
Depression may also be the risk factor for the development of dementia in people above the age of 60–65 years. Geriatric depression can either be a recurrence of a previous depressive episode experienced earlier at younger ages or a first-episode depression in late life.
Side effects of antidepressants:
Antidepressant drugs are the mainstay of treatment combined with psychological interventions. Elderly persons are more prone to side effects of antidepressant drugs even at lower doses. Customised full-time monitoring and motivation are often needed while treating patients with antidepressants. Geriatric depression with its multiple facets and as a disorder is a challenge to mental health practitioners treating the elderly.
Successful management of co-existing medical and psychological problems is possible through good teamwork between different medical teams and can at times be difficult to achieve.
Risks of suicide in the elderly:
Suicide is known to show a peak in two age groups, i.e., the adolescent and the elderly. Developed countries also depict a peak of suicide rate in the elderly compared to other ages. On the contrary, in India, the peak in the rate of suicide is seen in the age group of 15–29 years. Among the elderly, isolation and loneliness, loss of economic independence, and reduced social activity contribute to negative thought patterns.
The presence of serious, chronic medical illnesses is also considered to be a risk factor for elderly suicide. However, no direct link between the status of physical health and suicidal ideation or attempt has been established yet. Suicide is a neglected phenomenon in the elderly as suicidal ideation is rarely expressed by them and there is a dearth of suicide prevention programs for the elderly as compared to youth and adolescents. Suicide prevention in the elderly and bringing down suicide rates in geriatric populations are a major challenge for geriatric mental health.
Lack of large-scale awareness:
Mental health problems are under-identified by health-care professionals and older people themselves, and the stigma surrounding mental illness makes people reluctant to seek help. Lack of awareness, inadequate training opportunities, inequitable distribution of health resources, and the virtual absence of chronic care disease models are the challenges that confound the future of geriatric psychiatry in India. Government policies providing social benefits to the elderly population function adequately, but coverage is inadequate. For addressing geriatric mental health issues, the need of the hour is to increase awareness, capacity building, strengthening training and research activities, developing community-based rehabilitation programs, and developing a holistic primary health-care system.
There is a need to raise awareness in the public and other professionals about the unmet needs of geriatric mental health and develop adequate human resources. There is an urgent need to implement national policies, programs, and legislation targeting geriatric mental health and promoting advocacy and empowerment. Small and collaborative steps in all directions shall go a long way in improving geriatric mental health in India.