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Futurology and mental health services: are we ready for the demographic transition?

  • Moira Connolly (a1)
Summary

Planning for the future development of mental health services requires an understanding of the changing demographics of local populations. It is argued that the demographic transition faced by the UK requires mental health services to adopt an approach more typical of public health in responding to the needs of an increasingly ageing population.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Moira Connolly (moira.connolly@ggc.scot.nhs.uk)
Footnotes
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Declaration of interest

In July 2011 M.C. commenced a 2-year secondment to the Scottish Government as principal medical officer (mental health). The views in this article, however, are personal and have been developed over a time period preceding this appointment.

Footnotes
References
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1 Wikipedia. Future Studies. Wikipedia, no date (http://wikipedia.org/wiki/futurology). Accessed Feb 2012.
2 Grundy, E. Demography and public health. In Oxford Textbook of Public Health, Fifth Edition, Vol. 2 (eds Detels, R, Beaglehole, R, Lansang, MA, Guildford, M): 734–51. Oxford University Press, 2009.
3 Muijen, M. Challenging times for mental health services. Int Psychiatry 2010; 7: 12.
4 Kalache, A. Ageing worldwide. In Epidemiology in Old Age (eds Ebrahim, S, Kalache, A): 2231. BMJ Publishing, 1996.
5 Laidlaw, K, Pachana, NA. Aging, mental health, and demographic change: challenges for psychotherapists. Prof Psychol Res Pr 2009; 40: 601–8.
6 McCrone, P, Dhanasiri, S, Patel, A, Knapp, M, Lawton-Smith, S. Paying the Price. King's Fund, 2008 (http://www.kingsfund.org.uk/publications/paying_the_price.html).
7 Hanlon, P, Carlisle, S. Do we face a third revolution in human history? If so, how will public health respond? J Public Health (Oxf) 2008; 30: 355–61.
8 Kinsella, K. Demographic aspects. In Epidemiology in Old Age (eds Ebrahim, S, Kalache, A): 3240. BMJ Publishing, 1996.
9 General Register Office for Scotland. Scotland's Population 2010 – The Registrar General's Review of Demographic Trends. Edinburgh, 2011 (http://www.gro-scotland.gov.uk/files2/stats/annual-review-2010/j176746-00.htm).
10 Beaglehole, R, Bonita, R. Public health at the crossroads: which way forward? Lancet 2008; 351: 590–1.
11 Doyle, Y, McKee, M, Rechel, B, Grundy, E. Meeting the challenge of population ageing. BMJ 2009; 339: 892–4.
12 Martin, R, Williams, C, O'Neill, D. Retrospective analysis of attitudes to ageing in the Economist: apocalyptic demography or opinion formers? BMJ 2009; 339: b4914.
13 Colvez, A. Disability free life expectancy. In Epidemiology in Old Age (eds Ebrahim, S, Kalache, A): 41–8. BMJ Publishing, 1996.
14 Alzheimer's Society. Dementia UK 2007. Alzheimer's Society, 2007 (http://alzheimers.org.uk/site/scripts/download_info.php?downloadID=1).
15 The Future Vision Coalition. A Future Vision for Mental Health. The Future Vision Coalition, 2009 (http://www.newvisionformentalhealth.org.uk/A_future_vision_for_mental_health.pdf).
16 Lee, M. Improving Services and Support for Older People with Mental Health Problems. Age Concern. England, 2007.
17 Godfrey, M. Prevention: developing a framework for conceptualizing and evaluating outcomes of preventive services for older people. Health Soc Care Community 2001; 9: 8999.
18 Baltes, PB, Baltes, MM (eds). Psychological perspectives on successful ageing: the model with selective optimisation and compensation. In Successful Ageing: Perspectives from the Behavioural Sciences: 134. Cambridge University Press, 1990.
19 McMunn, A, Breeze, E, Goodman, A, Nazroo, J, Oldfield, Z. Social determinants of health in older age. In Social Determinants of Health (2nd edn) (eds Marmot, M, Wilkinson, R): 267–96. Oxford University Press, 2006.
20 Stephan, BC, Brayne, C. Vascular factors and prevention of dementia. Int Rev Psychiatry 2008; 20: 344–56.
21 Fratiglioni, L, Paillard-Borg, S, Winblad, B. An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurol 2004; 3: 343–53.
22 Fahy, N, McKee, M, Busse, R, Grundy, E. How to meet the challenge of ageing populations. BMJ 2011; 342: d3815.
23 Stafford, B, Duffy, D. Review of Evidence on the Impact of Economic Downturn on Disadvantaged Groups. Department for Work and Pensions Working Paper No 86. TSO (The Stationery Office), 2009.
24 Royal College of Psychiatrist, Mental Health Network, NHS Confederation, London School of Economics and Political Science. Mental Health and the Economic Downturn: National Priorities and NHS Solutions. Occasional Paper OP70. Royal College of Psychiatrist, NHS Confederation, LSE, 2009 (http://www.rcpsych.ac.uk/files/pdfversion/OP70.pdf).
25 Watt, G. Commentary on: what about the context in family medicine? Br J Gen Pract 2010; 60: 58.
26 Skuse, D. Mental health services in primary care. Int Psychiatry 2010; 7: 3.
27 Scottish Government. Towards a Mentally Flourishing Scotland. Scottish Government, 2009 (http://www.scotland.gov.uk/Publications/2009/05/06154655/0).
28 HM Government. No Health Without Mental Health: Delivering Better Mental Health Outcomes for People of all Ages. Department of Health, 2011 (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123737).
29 Anderson, D. Age discrimination in mental health services needs to be understood. Psychiatrist 2011; 35: 14.
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Futurology and mental health services: are we ready for the demographic transition?

  • Moira Connolly (a1)
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eLetters

Additional influences upon provision of mental health services

David N Anderson, Consultant Old Age Psychiatrist
26 June 2012

Connolly (1) makes many good points but some worthy of amplification.

Firstly, commentary on the ageing population is focused on increasingnumbers. Less often mentioned, but the critical factor, is the declining number in age groups traditionally providing informal care. In the European Union (EU) there are four people of 'working age' for each person over 65 and within 50 years there will be two (2). Add geographical movement of younger age groups away from parents, changing lifestyle and changing the role of women who provide the majority of informal care and this challenge is bothmultiplied and underestimated. If informal care declines (currently providing £8 Billion of care per annum for dementia alone in the UK) this will fall to the state. Here, the problem is not the attitude of younger people toward older generations but their availability to provide care.

Secondly, age discrimination legislation is a welcome step toward reducing inequalities of access to care though we have yet to see in whichdirection this driver drives us. It is naive to trust that legislation will inevitably solve these problems and there is justified concern that hidden indirect discrimination could drive us in the wrong direction (3). The law of unintended consequence is well known and why professional position statements and guidance remain important. Access to services is not sufficient to ensure equality.

Finally, there is need to address an increasing mental health workforce gap (3,4) where the greatest need for specialist expansion is old age psychiatry (5) yet it has the highest vacancy rate in specialist training, and, to redress previous policy discrimination against older people by positive action (3).

Aneurin Bevan described priority as the language of politics and so today's health and social care language is older people. Now is the time for a coordinated policy from government and professional bodies that makes explicit this priority because we cannot complacently wait for natural events to bring solutions. This message needs to be clear. Whilehope is invested in ageing bringing more years of life in good health, andthat may happen, current data are showing the opposite (2).

References:

1.Connelly M. Futurology and mental health services: are we ready for the demographic transition? Psychiatrist 2012; 36: 161-42.Fahy N, Mckee M, Busse R, Grundy E. How to meet the challenge of ageing populations. BMJ 2011; 342: d38153.Anderson D. Age discrimination in mental health services needs to be understood. Psychiatrist 2011; 35: 1-44.Draper B, Anderson D. The baby boomers are already here - but do we have sufficient workforce in old age psychiatry? Int. Psychogeriatrics 2010; 22: 947-95.Centre for Workforce Intelligence. Recommendation for Medical Specialty Training 2011. Centre for Workforce Intelligence 2011

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Conflict of interest: None declared

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The need for age appropriate forensic services

Pratish B Thakkar, Consultant Forensic Psychiatrist
08 June 2012

We read with interest the editorial by Dr Connolly on the planning for the future development of mental health services. It has been rightly pointed out the planning for the development of mental health services requires an understanding of the changing demographics in the country.

We feel every directorate within psychiatry will need to prepare for the demographic transition through thoughtful planning in service development that can provide quality as well as appropriate care to the elderly. We felt that within forensic services, a serious thought should be given to development of geriatric forensic service.

Traditionally, it is believed that there is a low crime rate in the elderly, increasingly; studies have shown that there is an increase in criminal behaviour among those 60 or over (Fazel and Jacoby, 2001). The number of people in prison over the age of 60 has increased from 1.3% to 2.4% in England (Home Office).

A study by Needham-Bennett concluded that there is a high prevalence (28%) of psychiatric disorders in alleged offenders, in the community, aged 60 years and over. Studies done in the prison populations conclude that the prevalence of psychiatric disorders among remanded male prisonersaged 55 years and over was 50% (Taylor and Parrott, 1988); and in sentenced was 53% (Fazel 2001).

Moreover up to 50% of elderly offenders with psychiatric disorders have a physical illness (Barak 1995). In addition they may have visual impairment (21%) auditory impairment (42%) mobility problems (28%) and cognitive impairment (22%) (Ticehurst et al., 1992; Curtice et al., 2003).

Currently forensic mental health units with long term rehabilitation wards providing care for elderly individuals. This longer term admission isusually due to ongoing risks combined with difficulties in rehabilitating them due 'institutionalism' or ongoing mental health issues. We wondered if such units equipped to be able to deliver care for older individuals with increasing physical co-morbidities or developing certain organic conditions such as dementia. Other issue we feel that need consideration is the use of risk assessment tools such as Historical Clinical Risk Management 20 (HCR-20) in older age group in forensic units that are generally used for working age group. It is our view that the current psychological treatment programmes like the sexual offending treatment programme will need modifications for this client group.

Hence, we feel that the complex needs of elderly mentally disordered offenders appear to fall within the domains of geriatric psychiatry services and forensic psychiatry services, but they may not be met by either service aloneConsideration should be given to setting up specialist tertiary forensic geriatric psychiatry. There has been some initiative in the independent sector in this matter.

Refrences:-

Seena Fazel, Tony Hope, Ian O'Donnell, Robin Jacoby. Hidden psychiatric morbidity in elderly prisoners. British Journal of Psychiatry 2001; 179:535-9

P J Taylor and J M Parrott Elderly offenders. A study of age-related factors among custodially remanded prisoners. British Journal of Psychiatry 1988 152:340-6;

Seena Fazel, Tony Hope, Ian O'Donnell, Robin Jacoby. Hidden psychiatric morbidity in elderly prisoners. British Journal of Psychiatry 2001; 179:535-9.

Needham-Bennett, H., Parrott, J., & MacDonald, A.J.D. (1996) Psychiatric disorder and policing the elderly offender. Criminal Behaviourand Mental Health, 6, 241-252.Martin Curtice, et al The elderly offender: an 11-year survey of referralsto a regional forensic psychiatric service Journal of Forensic Psychiatry & Psychology Volume 14, Issue 2,Barak, Y., Perry, T., & Elizur, A. (1995). Elderly criminals: a study of the first criminal offence in old age. International Journal of Geriatric Psychiatry, 10, 511-516

Moira Connolly Futurology and mental health services: are we ready for the demographic transition? The Psychiatrist Online May 2012 36:161-164

Ticehurst S, Ryan M, Hughes F (1992) Homicidal behaviour in elderly patients admitted to a psychiatric hospital. Dementia 3: 86-90

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Conflict of interest: None declared

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