The WPA-IPS-SPF-AFPA Joint Panel Discussion Organized by the IPA: Voices from South Asia Regarding Older People’s Mental Health Advocacy and Services

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THE IPA OLDER ADULT MENTAL HEALTH AWARENESS WEEK

For more than 40 years, the International Psychogeriatric Association (IPA) has provided global leadership and training in the mental wellbeing, mental healthcare, and rights of older persons. Comprised of multi-disciplinary members from across the world, the IPA is involved in education, care, and innovation across various societal segments enabling healthy ageing, longevity, participation, and inclusion among older people so that they can be a vital resource to their families, communities, and economies.

As a unique initiative this year, the IPA organized the Older Adult Mental Health Awareness Week, RUNNING from October 1^st (United Nations International Day for Older Persons) to October 10^th (World Mental Health Day). This ten-day span was made up of daily programs that witnessed global societies, associations, and leaders coming together to advocate the promotion of mental health, mental wellbeing, and successful ageing among older adults. There was a wide variety of online resources for older adults and their caregivers on mental health education, dementia caregiver training, healthy ageing initiatives, etc., followed by downloadable graphics and social media promotions. Also, there were video messages from international dignitaries (including the World Health Organization Director General), virtual sessions from delegates worldwide, and a curated list of books, movies, podcasts, etc., for public awareness as an attempt to battle stigma and ageism.

VOICES FROM SOUTH ASIA: THE PREMISE

As a part of this special initiative, the IPA organized a session on October 6^th entitled “Mental healthcare services and advocacy for the older people amidst COVID crisis: Voices from South Asia”. This program was jointly coordinated by the World Psychiatric Association (WPA), the Indian Psychiatric Society (IPS), the Indian Association of Geriatric Mental Health (IAGMH), the SAARC Psychiatric Federation (SPF), and the Asian Federation of Psychiatric Associations (AFPA). This was the first time that two international psychiatric associations came together with the regional bodies of South Asia to discuss and advocate mental healthcare in older people.

Asia has some of the fastest developing economies and largest conglomerations of populations in the world. One such geographically unique region is South Asia, which accounts for nearly 25% of the global population and one-fifth of the psychiatric morbidity worldwide. This region is also ageing rapidly compared to rest of the world due to modifications in healthcare facilities, hygiene, and lifestyle, as well as improved sanitation and infection control. Further, some of the South Asian countries have also been amongst the worst-hit by the COVID-19 pandemic, which has led to an exaggerated psychosocial crisis among their older populace. Many of these nations face issues with community psychiatric care, trained manpower, socio-economic resources, legislation catering to psychological care, and health inequalities. However, recent years have also witnessed a paradigm shift in mental health policies, infrastructure, and technology among these nations. Climate changes, migration, displacement, and ecological characteristics further make South Asia unique in terms of the region’s mental health needs and challenges.

Participants:

This first-of-its kind discussion was attended by a panel of global leaders: Dr. Afzal Javed (President, WPA), Dr. Gautam Saha (President, IPS), Dr. G. Prasad Rao (President, IAGMH and President Elect, AFPA) as well as Dr. Sudarshan Narsingh (President, SPF).

 

 

It was moderated and organized by Dr. Debanjan Banerjee (Consultant Geriatric Psychiatrist, India on behalf of the IPA organizing committee).

The panel discussion was centered around the following themes:

• A global perspective on the challenges facing older people during the ongoing COVID-19 pandemic: Why prioritize?
• Specific challenges in the mental healthcare of older people in South Asian countries
• Role of the various regional psychiatric societies (IPS, IAGMH, SPF, AFPA) in dealing with this problem statement
• Rights and dignity-based mental healthcare in older people during the COVID-19 pandemic: lessons learnt in these nations
• Role of the WPA in coordinating with the regional societies for the betterment of promotive, preventive, curative, and rehabilitative mental health services for older people
• Cross-nation collaboration and evidence-based interventions: future directions

SETTING THE DISCUSSION IN CONTEXT

Dr. Banerjee kickstarted the session by setting the premise. The South Asian region is facing rapid population ageing, which has strategic implications. Aging populations present a plethora of challenges with regard to the economy, societies, and governments. It can slow financial growth, leading to inequality and poverty among older people with unequal intergenerational wealth transfer. This can be further compounded by labor market inefficiencies, a shift of dependency ratio, and unsustainable pensions. Such socio-economic and demographic challenges have been reflected in the recent Longitudinal Aging Study of India (LASI), the first of its kind, modelled on the classic Health and Retirement Study. The first-wave data (2017–2018) not only reveals an increase in depression, anxiety, and neurocognitive disorders but also decreased social participation, reduces perceived life satisfaction, results in financial crisis in the older population, and inadequate awareness about the limited policies and social schemes geared towards their welfare. These factors become all the more relevant in the psychosocial care of older people, as this World Mental Health Day 2021 was themed “Mental Health in an unequal world” by the World Federation for Mental Health (WFMH).

Dr. Javed summarized the existing evidence that older people face biopsychosocial vulnerabilities and existential threats during the COVID-19 pandemic. Further, the risk of increased morbidity and mortality due to the infection, the direct neuropsychiatric effects of the virus, and increased propensity for ‘long COVID’, and other specific challenges are highlighted in Table 1.

 

Table 1. Unique challenges among older people during the COVID-19 pandemic

Medical	Psychosocial
Chronic physical illnesses	Risk of elder abuse
Pulmonary comorbidities	Loneliness and social isolation
Multiple hospital visits/stays	Existential threats
Frailty	Grief and bereavement
Polypharmacy	Ageism
Gait and mobility concerns	Lack of domestic help and social support
Sensory and cognitive deficits	Reduced independence
	Prone to misinformation
Vulnerable groups: women, migrant workers, frontliners, lower socio-economic status, sexual minorities, etc.

 

The WPA has always been on the forefront of advocating for older person’s rights and person-centered mental healthcare. The WPA Section of Old Age Psychiatry (WPA-SOAP), presently led by Dr. Carlos Augusto de Mendonca Lima, has been phenomenal in terms of its work towards elder abuse prevention, fighting ageist attitudes, encouraging inclusion among people living with dementia, and caregiver education, all of which have become even more relevant during the pandemic. Several researchers across the world, including members of WPA-SOAP, the International Longevity Centre (ILC), Canada, and IPA have contributed to the recently published Special Issue of the American Journal of Geriatric Psychiatry, entitled “Combating Ageism, Mentalism and Ableism: It’s time for a United Nations Convention on the Human Rights of Older Persons”. It specifically focused on human rights, dignity, ageism, and discrimination in older adult mental healthcare.

Dr. Javed also gave a reminder of the Consensus Statement on Ethics and Capacity in older people with mental disorders developed by the WPA-SOAP in 2008. This offers clinicians, allied professionals, and the general public a constructive yet practical framework for upholding the ethical needs and standards of older people living with mental illnesses. However, the implementation and awareness in many low- and middle-income countries (LMIC) remain a real world challenge.

Dr. Sudarshan Narsingh concurred that Nepal has been ravaged by both the waves of COVID-19 and has a dire need for specialist old age mental healthcare services. Overall, the country’s mental health manpower is itself grossly inadequate and strengthening primary healthcare services and psychological first aid in psychogeriatric care would represent a first right step in many South Asian nations. The inequalities in older persons have been further widened by COVID. He further stressed the need for individual-based care and treatment, dementia prevention and memory clinics, culturally relevant cognitive assessments, a wider range of geriatric services, coordinated training in mental healthcare among older persons, home-based and institutional services, as well as appropriate caregiver education.

Dr. Saha and Dr. Prasad Rao reflected on the various activities organized by the IPS and IAGMH during COVID-19. The IPS has published several manuals (check key references) for psychiatric management, the mental healthcare of general physicians, and the wellbeing of older people in coordination with the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, and the Ministry of Health and Family Welfare (MoHFw), Government of India. Besides, the landmark Telepsychiatry and Tele-psychotherapy guidelines have recently been jointly released by the IPS and NIMHANS, Bangalore, which marks a paradigm shift towards the “new normal” of mental healthcare services during and post-COVID. Tele services are especially relevant for older people in more ways than one, and help in the coverage of wider and remote areas which do not have adequate specialist care. A special IPA Bulletin Issue: Telehealth is dedicated to highlighting global research on digital services in geriatric mental healthcare. However, the implementation, connectivity, and ethical issues still remain a significant challenge, with further training needed among practicing psychiatrists. Also, due to sensory and cognitive deficits, risk of abuse, increased dependency, and poor digital literacy, telecare services also need to be optimized and tailored for older people.

The IPS and IAGMH have coordinated several postgraduate courses on geriatric psychiatry covering dementia, severe and common mental health disorders, grief and loneliness in older people, and psychotherapy in this population. Three-year comprehensive postdoctoral (Doctorate of Medicine) courses already exist in two apex Indian institutes and many more are in the pipeline. This discussion also brought about the need to include human rights, end-of-life, social cohesion, and forensic issues, and preventive aspects in the mental healthcare of older people. Community-based care is the need of the hour, and all the panelists concurred that “geriatric psychiatry cannot be practiced in a room”.

ACTION AREAS IN THE MENTAL HEALTHCARE OF OLDER PEOPLE IN SOUTH ASIA

The central themes of the session were the need to implement psychiatric training (inclusive of models of old-age mental healthcare) in undergraduate (MBBS) curricula, community education, and the role of the media in preventing what is currently widely prevalent ageism and, finally, a concerted effort from all the South Asian nations to conduct a systematic survey to explore the post-COVID state of affairs in terms of psychiatric morbidity in older people, their unmet needs, mental healthcare services available, and social service utilization. This will serve as a framework to set up a ground-reality of mental healthcare for older people in these nations, which will in turn enable the development of evidence-based clinical and community interventions. This will also strengthen constructive dialogue with policymakers about the resources and support necessary to promote mental wellbeing among older persons. HelpAge India has very recently published their report “COVID-19 and the elderly: The silent tormentor” which reveals a concerning rise of abuse, decreased self-perceived health status, reduced priority for vaccination, low rates of digital literacy, and ageism. Similar core evidence will form the roadmap of both undergraduate and postgraduate training, as well as policy interventions in all the countries. Further cross-nation collaboration is imperative, and Dr. Javed gave the assurance that the WPA will always serve as an encouraging guide for all endeavors related to mental healthcare. The various areas of collaboration are highlighted in Table 2.

 

Table 2. Areas discussed for improving mental healthcare for older people under the guidance of the WPA

• Context-specific standard ethical guidelines for capacity assessment • Community-based mental healthcare models for older people • Mental health education: involvement of community and the media • Memory clinics with the help of regional resources (ex: ARDSI) • Rehabilitation and training subspecialty in old age psychiatry • Educational content, pedagogy resources, training fellowships for MHP • Composite UG and PG curriculum inclusion related to old age mental healthcare • Regional priorities for research, epidemiology of old age mental health concerns, evidence-based interventions • Cross-nation collaboration and research funds • Integration of primary-tertiary mental healthcare • National mental health programs and policies: tailored to the needs of older people • NGO collaborations • Optimizing telepsychiatric services and dementia care • Legal framework for battling ageism and elder abuse • Rights-based (as opposed to symptom-based) old-age mental healthcare • Inclusion of lived experiences (service users) in service and policy

Note: ARDSI: Alzheimer’s and related Disorders Society of India; MHP: mental health professionals; UG: undergraduate; PG: postgraduate; NGO: non-governmental organizations.

 

Telepsychiatric tools need to be utilized to train primary care physicians, grassroot-level health workers, and community health workers, who essentially form the backbone of any nation’s mental health infrastructure.

National mental health policies are present in only four countries: India, Nepal, Bhutan, and Pakistan. However, many of these need community integration, amendment, and implementation. Also, related mental health programs that are sensitive to the needs of older people are mandatory. The recently revamped Mental HealthCare Act 2017 (MHCA) passed by India is largely based on the United Nations Convention on Rights for People with Disabilities (UNCRPD), and could serve as a learning anchor for other nations in South Asia, although Dr. Saha and Dr. Prasad Rao both cautioned that the Act is still far from older people-friendly and needs to be further revised to be fully geared toward addressing their wellbeing and needs. Dr. Banerjee added that qualitative interpretative studies are highly valuable in this regard as “lived experiences”, and the unheard voices of the service user older people and their families need to form part of both services and policy decisions.

Centralization of mental health delivery systems has been a major drawback in many of these nations, which are now slowly transiting to the community. This is relevant to older people who have been further segregated, isolated, and lonely due to the pandemic, social distancing, and poor digital literacy. Hence, improving awareness, autonomy, independence, equality, and literacy among older people are key to making the mental healthcare in these nations more friendly towards them.

Resonating the words of Dr. Trivedi and colleagues in their paper in World Psychiatry (2007), the panelists came to the consensus that:

“The organization and coordination of the above-mentioned array of activities related to the development of mental health services need a focal point. Therefore, it is very much appropriate at this juncture to establish an institution which could be developed to be a center of excellence on mental health in the SAARC region.”

Editorial comment:

This Conference report has been published in the IPA Bulletin Volume 38, No. 4 (December 2021). It is a non-indexed digital news bulletin for the IPA (only open to IPA members).

Copyright rests with the authors.

Link to the program: https://awarenessweek.ipa-online.org/resources/2021/6-october/6-october-voices-from-south-asia

Funding: The article was written without external funding.

Conflict of interests: No conflicts of interest to disclose.

About the authors

Debanjan Banerjee

Apollo Gleneagles Multispecialty Hospitals; Advocacy and Public Awareness Committee, International Psychogeriatric Association (IPA)

Author for correspondence.
Email: dr.djan88@gmail.com
ORCID iD: 0000-0001-8152-9798
Scopus Author ID: 57191832268
https://www.researchgate.net/profile/Debanjan-Banerjee-3/research

Consultant Geriatric Psychiatrist; Vice-chair

India, Kolkata

Afzal Javed

World Psychiatric Association (WPA)

Email: afzalj@gmail.com
ORCID iD: 0000-0003-2518-0688

President

Switzerland, Geneva

G Prasad Rao

Asha Hospital; Indian Association of Geriatric Mental Health (IAGMH)

Email: prasad40@gmail.com

Consultant Psychiatrist; President

Hyderabad; Mumbai

Gautam Saha

Clinic Brain Neuropsychiatric Institute and Research Center, Barasat; SAARC Psychiatric Federation (SPF)

Email: editor@consortium-psy.com

MD, Director; President

India, Kolkata; Kathmandu, Nepal

Sudarshan Narsingh Pradhan

Kathmandu Medical College Teaching Hospital

Email: editor@consortium-psy.com
ORCID iD: 0000-0001-7459-7207

MD, Professor and Head, Department of Psychiatry

Nepal, Kathmandu

References

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