Mental Health-Care Delivery for Older People in China: An Update of Challenges and Recent Clinical Research

Challenges in Mental Health-Care Delivery for Older People in China

In the new millennium, China is facing rapid population aging due to a generation of one-child policy and an increase in life expectancy. By the end of 2017, China had 240 million people aged 60 years and above (ie, the locally defined age cutoff for “older people”), which accounted for 17.3% of its whole population. Currently, China has the largest aging population worldwide. ¹ By 2050, a staggering figure of around a third of Chinese people will be over 60 years. ² Such rapid demographic shift in aging population is associated with many social and health problems, in particular mental health issues. For example, negative life events, such as widowhood, and major physical diseases, in older people could increase the risk of mental problems. ³ In addition, the traditional Chinese extended family structure has collapsed due to the one-child policy, resulting in countless older people living alone or only with their spouse (ie, the so-called “empty-nesters”). ⁴ The proportion of “empty-nesters” have increased significantly, affecting nearly half of all older population in China. ⁵ Compared to those living with children, “empty-nesters” are more at risk of suffering from mental health problems. In this article, we outline some challenges in delivering mental health care for the older population in China.

Until recently, epidemiological data of psychiatric disorders in older people have been lacking. The first national survey of psychiatric disorders conducted in China between July 2013 and March 2015 ⁶ found that the 12-month prevalence of psychiatric disorders (excluding dementia) in older people aged 65 years and above was 4·9% (95% confidence interval: 0.8%-9.1%). The implementation of the first National Mental Health Law in 2013 is a milestone in mental health development in China since the legislation provides the legal framework to protect patients’ rights and ensure the appropriate treatment. ⁷ However, the Mental Health Law does not refer specifically to older people with psychiatric disorders even though this population has different clinical needs compared to other age groups, such as cognitive problems and impaired decision-making capacity.

Compared with many other countries, the mental health resources in China remain inadequate. For example, the proportion of psychiatrists was 2.02 per 100 000 in China in 2015, ⁸ which is lower than the corresponding figure in Japan (20.1 per 100 000), ⁹ but higher than that in India (0.3 per 100 000) and Thailand (0.87 per 100 000). By the end of 2015, inpatient service for geriatric psychiatry was available in 385 hospitals with 28 118 beds nationwide, ¹⁰ and most of these mental health facilities were only accessible in urban areas. Currently, there is no fellowship training program in geriatric psychiatry in China and psychiatric trainees have variable exposure to geriatric psychiatry.

Suicide is a major mental health challenge in China. In 1990s, the annual suicide rate reached 23 per 100 000 population, which accounted for around a third of suicides globally. ¹¹ Following the implementation of suicide prevention services, increased access to mental health services and particularly the strict control of pesticides in rural areas (where pesticide use is the most common suicide method), the estimated suicide rate in China reduced to 9.8 per 100 000 population during the period of 2002 to 2011. ¹² However, the suicide rate in older people remained high; 44% of all suicides occurred in people aged 65 or older during 2009 and 2011. The likely contributing factors include poor physical health, financial difficulties, interpersonal conflicts, and social isolation. ¹³ Therefore, effective measures of suicide prevention for Chinese older people are urgently needed.

The global trend of downsizing and eventual closure of stand-alone psychiatric hospitals with concurrent expansion of community-based mental health services has not been implemented in China, where the vast majority of mental health services are delivered by psychiatric hospitals. To address social stability and harmony, a national community-based mental health system has been established since 2004 for adult psychiatric patients with high risk of aggressive behaviors. ⁸ However, no specific community mental health services for older people with psychiatric disorders have yet been developed. In fact, the hospital-based psychogeriatric services are mostly found in urban areas, which are inaccessible for around half of older population living in rural areas.

Finally, due to age-related physical and pharmacokinetic changes, older people with psychiatric disorders are likely to have poor general physical health and drug-induced adverse effects. ^14,15 Therefore, treatment guidelines for general adult patients cannot be extrapolated to the older population. The first clinical guidelines in China for the prevention and treatment of psychiatric disorders were developed by the Chinese Medical Association in 2003, ¹⁶ while the second guidelines for the treatment of schizophrenia, bipolar disorder, and depressive disorders in China were developed in 2015. ¹⁷ However, there is a lack of customized clinical guidelines for older patients, which are urgently needed given the aging population in China.

In summary, despite the significant progress achieved in the mental health development in China, there are existing challenges in the provision of mental health services for the rapidly growing aging population. In particular, comprehensive epidemiological data and development of accessible and age-appropriate mental health services for this population are immediate priorities.

Recent Clinical Research in Geriatric Psychiatry and Related Fields in China

Despite the increasing research in geriatric psychiatry and related areas in China, most findings are published in Chinese language journals, which are inaccessible for the international readerships. Therefore, it is useful to summarize the recent clinical research on major psychiatric disorders and neurological diseases, such as dementia, depression, suicide, and stroke, in Chinese older adult population. This special issue of the Journal of Geriatric Psychiatry and Neurology brings together a group of clinical researchers in China to address these issues.

In recent decades, primary health services have become both accessible and affordable in most areas in China. Although more than half of Chinese old people have access to treatment in primary care services, mental health services are not available in most primary care services across China. Psychiatric disorders, such as depression, are common in old people, especially in those suffering from chronic physical diseases. However, the epidemiology of depression in older people treated in primary care is not well studied. Zhong et al ¹⁸ examined the prevalence and demographic and clinical correlates of depression in older people treated in Chinese primary care.

Deficit schizophrenia is a subgroup of schizophrenia characterized by primary negative symptoms, associated with different pathophysiological and clinical features compared to nondeficit schizophrenia. Approximately 15% of first-episode schizophrenia and up to 30% of chronic schizophrenia patients meet the diagnostic criteria of deficit schizophrenia, but the pattern of deficit schizophrenia in older patients is not clear. Liu et al ¹⁹ investigated the prevalence of deficit schizophrenia in older patients with schizophrenia and the related demographic and clinical features.

Suicide in older people is a public health challenge with rates being significantly higher in older adults, particularly in rural areas of China. Poisoning by pesticides is a common suicide method because pesticides are easily available in rural areas. However, use of different suicide methods is also associated with social–cultural, physical, psychological, and biological factors. Due to the high suicide rate in older people, suicide preventive measures have gained much attention. Zhu et al ²⁰ conducted a psychological autopsy study to compare the demographic characteristics, suicide behaviors, impulsivity, mental disorders, depressive symptoms, and social support in older people who committed suicides using pesticide and those using other means.

The burden of severe mental illness is high in Chinese older people; therefore, it is important to provide appropriate mental health services to this population. To date, little is known about treatment status and patterns in older people with severe mental illness in China. Chen et al ²¹ examined the treatment status of older patients with schizophrenia, bipolar disorder, or major depressive disorder in rural areas of China and explored their associated factors. They used the Andersen’s behavioral model, a theoretical framework for health services use in older population, which includes individual determinants of health service use: predisposing, enabling, and need.

Due to the improvement in general health care, many patients with schizophrenia are living into older adulthood. Compared with their younger counterparts, older patients have poorer physical health, more frequent use of multiple medications, lower pharmacokinetic clearance, and higher risk of drug–drug interactions, all of which could increase their susceptibility to antipsychotic-induced side effects. Therefore, antipsychotic prescription patterns for older patients with schizophrenia are likely to be different from younger patients. Dong et al ²² conducted a multicentre survey in Asia including China to examine the prescription pattern of psychotropic medications, particularly antipsychotic polypharmacy, in older patients with schizophrenia. Regular surveys on prescription patterns of psychotropic medications are an efficient way to examine the treatment rationale and trends of specific treatments over time.

Mild cognitive impairment (MCI) refers to an intermediate stage of cognitive impairment between healthy aging and dementia. Older persons with MCI have an increased risk of developing dementia than individuals without MCI. Subclinical depression is defined as the presence of depressive symptoms that do not fully meet the diagnostic criteria of major depression. The neurobiology of subclinical depression is perhaps associated with the degenerative processes that underlie Alzheimer disease (AD). Sun et al ²³ examined the relationship between subclinical depression and cognitive deficits in patients with MCI and also investigated the characteristics of specific cognitive domains and profiles in patients with MCI having subclinical depression. Amnestic mild cognitive impairment (aMCI) is usually viewed as the prodromal stage of AD and persons with aMCI are more likely to present with early memory impairment compared to healthy old people. Subjective cognitive decline, defined as self-perceived cognitive decline while having normal performance in objective cognitive assessment, has been viewed as an even earlier symptomatic marker of AD than aMCI. Some studies found that differentiating aMCI from normal controls was much easier than differentiating subjective cognitive decline from normal controls using brain atrophy measures. Zhao et al ²⁴ conducted a study with the recent conceptual framework of subjective cognitive decline and examined the brain volumetric differences among aMCI, subjective cognitive decline, and normal controls.

Stroke in patients can lead to high levels of disability which is significantly associated with the severity of neurological deficits immediately following an acute stroke. Both the instrumental activities of daily living (IADL) and the basic activities of daily living (BADL) are widely used to measure functional status in patients with strokes. Qu et al ²⁵ investigated the association between preexisting cerebral abnormalities and functional outcomes measured by IADL and BADL scales in patients at different poststroke follow-ups. Cerebral small vessel disease (SVD) is a major cause of poststroke cognitive impairment, which could impede physical rehabilitation and increase the risk of stroke recurrence. The studies on the relationship between SVD burden and disability, and stroke recurrence have shown mixed findings. However, earlier studies were mostly cross-sectional or of short-term follow-up periods. Liang et al ²⁶ tested the predictive value of the SVD score in determining cognitive dysfunction in the first year after stroke in patients with acute ischemic stroke.

The above recent studies in geriatric psychiatry and related areas will help international readerships gain new insight into the various psychiatric disorders and related problems in China. It should be noted, however, that most studies are cross-sectional, which may limit the clinical significance of their findings. In the future, more prospective cohort studies and randomized control trials are warranted to advance the field of old age psychiatry in China.