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Could day clinics be the answer for elderly people with mental-health issues?

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The baby boomers are longer-lived than previous generations, but they still experience similar rates of mental illness. Day clinics may be the way to address this concern.

When most of us think of elderly mental-health problems, we think of dementia and Alzheimer’s disease. But psychiatric disorders such as depression and anxiety are rife in older people, too, and they often go undetected and undertreated.

It’s a problem that’s set to get worse as ageing baby boomers put pressure on health services. Although lifespans have doubled in developed countries during the past 200 years, “healthspan” – healthy, disease-free lifespan – hasn’t increased at the same rate. That includes mental illness.

But the mental-health needs of older people differ from those of the young. How should older people be cared for? Perhaps, as suggested by a recent study at New Zealand’s only psychiatric day hospital, the Canterbury District Health Board’s Burwood Day Clinic, some of them would do best at a mental-health day clinic. It’s a place that bridges the gap between community care and hospital.

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The study, published in the New Zealand Medical Journal in August, included data collected since 1987 and involved 380 patients aged 65 years and older, most of whom were cognitively unimpaired. It found that all measures of mental well-being increased from intake to discharge, and that day-hospital treatment for older people may be an effective method of treating psychiatric disorder.

The author, Burwood clinical psychologist Petra Ann Hoggarth, cautions that the study can’t definitively say that day clinics do cause improvements to elderly mental health; there was no control group, for one thing. And psychogeriatric day hospitals are an astonishingly poorly studied area; Burwood’s is only the second-ever study on this topic and comes 17 years after the previous one was published on a German day clinic (which also found day hospitals helped improve mental health for older people).

But this study does suggest the clinics may help those older adults in the grey area of mental-health care – they have more needs than can be addressed at home, but they don’t need hospital admission. It suggests we could do with more mental-health day clinics such as Burwood.

Petra Ann Hoggarth.

In a supporting editorial, Matthew Croucher, a psychiatrist of old age and University of Otago senior clinical lecturer, says he was once ambivalent about the value of day clinics, not least because of the cost. But, since beginning work at Burwood in January this year and seeing meaningful rehabilitation, he’s changed his mind.

“I have seen for myself that with older persons’ anxiety and depressive disorders in particular, but also with cognitive impairment and psychosis at the milder end of the spectrum, being part of a community of care is not just a nice-to-have but is critical for some folk to gain the trust required to form a meaningful therapeutic alliance,” he wrote. “Rehabilitation does meaningfully take place in this artificial environment, in no small part because it is not ‘real life’. The day-hospital patients and staff do indeed become a ‘tangata whaiora’ – a community of people moving towards health.”

However, outside hospital, how do you create a “community of care” in the wider population, supporting all people with mental illness? We could learn from work being done with dementia patients in South Korea.

The country has declared a “war on dementia”, which includes day dementia-care and prevention clinics, such as one in Gangseo District, Seoul.

Gangseo District has the second-largest population of elderly people in Seoul – 70,000 of the 570,000 residents are older than 60. South Korea started its dementia war in the early 2010s, embarking on a focused approach to readying the country for its coming tsunami of cognitively impaired citizens, one consequence of having the world’s fastest-growing ageing population.

At the care centre, one of 25 in Seoul, the bright and cheerful rooms are full of halmoni and halabeoji (grandmothers and grandfathers) exercising, chatting, playing games, making art and doing other exercises to strengthen their neural networks. There are sports and music classes, with the aim of giving dementia patients a sense of participation and accomplishment, as well as family outreach.

Matthew Croucher.

The facilities are focused on dementia care, not mental illness, but their proliferation is an example of what can happen when a country aggressively targets a health problem such as dementia, invests in prevention early, and focuses on education to reduce stigma and bias.

South Korea created programmes to help people recognise signs of cognitive decline and how to interact with those who have it, helping them retain dignity and quality of life and reducing its “scariness”. The programmes, aimed at everyone from kindergarteners to bus drivers, reduce stigma by demystifying dementia, demonstrating what it is like to suffer from it, and giving advice on how to cope when relatives’ brains begin to fade.

It means that South Korea is an increasingly dementia-ready nation. However, the model could be applied to mental illness as well.

Back in New Zealand, looking beyond Burwood and its success in psychogeriatrics, what would happen if we did the same for our mentally ill as South Korea has done for those with dementia? If we created a community of care outside clinic walls?

A nationwide strategy of caring for people with mental illness shouldn’t just focus on the sick, but also on educating and eliciting compassion and understanding in others – including employers, family members, kindergarteners, and yes, bus drivers, too.

The Government Inquiry into Mental Health and Addiction will be out in late November. In his NZMJ editorial Croucher also said, “Joining [Burwood] has opened my eyes to the importance of taking a thoughtful look at what staff, patients and care partners say, and of contextualising this within an overview of services as a whole when coming to a view about the merit of a service.” Hopefully, the inquiry has done this as well – and New Zealanders should, too. Helping people with mental illness shouldn’t just mean encouraging them to reach out. It should focus on ensuring others can confidently and compassionately reach in.

This article was first published in the October 27, 2018 issue of the New Zealand Listener.