Mental health services for older people.

Sir,

The article on mental health care of older people published in the journal[1] made certain observations about the mental health care services for older people. Authors found significantly more older people making use of the outpatient clinics run by the District Mental Health Program (DMHP) in comparison that of the medical college. The newly initiated DMHP of Palakkad district, though called as Community Mental Health Program, functions very much like other DMHPs, except that the funds come from the National Rural Health Mission. We started 20 new monthly out-patient clinics in various parts of Palakkad, a district with predominantly rural population. It has vast areas, which are remote, difficult to reach. There are also areas which are mostly inhabited by tribal population. We saw a total of 1029 new cases during an 8 months period, starting from April 2013. All of them were assessed and diagnosed by a psychiatrist or a clinician trained in psychiatry using International Classification of Diseases-10 guidelines. There were 137 people aged 60 years or more among those who sought our help. Older people thus constituted 13.3% of the patients seen. The proportion of older people seen at the outpatient clinic at the medical college hospital in the neighboring Thrissur district during the same period was only 6.2%. This indicates that the decentralized services provided through the outreach clinics of DMHP are better utilized by older people. Our observations are similar to that of Tharayil et al.[1] and the DMHP seems to be an important step forward in meeting the mental health needs of older people. Geriatric mental health is an important area for service development in the future.

Access to care is an important barrier for dementia care. It is not easy to reach even the primary care settings. We saw 18 patients with dementia at the DMHP clinics, which are located in to primary care facilities. We expect to see many more. All DMHPs should be geared to meet the mental health needs of older people and dementia care should become an important component of the services. Provision of user friendly services through the DMHP clinics would be a great help to those who suffer from dementia. However, this is not enough. Clinic based services will become more effective if we link them with in effective community outreach program.

We can use the dementia module of Mental Health Gap Action Program intervention guide[2] to train nonspecialist care providers. This module was developed by the World Health Organization taking note of the sociocultural context and the resource limitations of the developing regions of the world. Following brief training, these Accredited Social Health Activists (ASHAs), can identify dementia cases and provide support to home-based dementia care. The provision of information, education and support to the families can be monitored by the DMHP team. This task can be carried out by the, medical officer, clinical psychologist, psychiatric social worker or the nurse. We use printed caregiver information booklets in the local language to provide useful tips to caregivers. We also found this booklet to be useful in the training for ASHAs.

We are now exploring the possibility of collaborating with the state wide network of palliative care workers to provide community care for people with dementia in Kerala. These trained palliative care volunteers are often asked to see functionally impaired older people during their community work.[3] Many of them suffer from disabling conditions like dementia. Linking of palliative care initiatives with the DMHP can save costs and lead to better use of community resources. The members of the DMHP team can take up the responsibility of providing guidance to palliative care workers. They can also provide outpatient dementia care services through the monthly DMHP clinics.

Meeting mental health needs of older people is major public health challenge we face. Equipping DMHP program to offer better mental health care for older people appears feasible and this can be one of the many strategies aimed at reducing the huge treatment gap that exist in dementia care in India.[4]