Guest Editorial
Geriatric Psychiatry: A Subspecialty Whose Time Has Come
Nathan Herrmann, MD, FRCPC1
What is geriatric psychiatry? Simply put, it is the subspecialty dealing with the assessment and management of mental disorders occurring in late life—a period occasionally and somewhat arbitrarily defined as aged 65 years and over (1). This definition falsely simplifies what we do as geriatric psychiatrists and does not acknowledge the scope of practice and the specific skills requisite to this subspecialty. The following are just some of the necessary skills and requirements: an awareness of the physiology of aging and how it affects the pharmacokinetics and pharmacodynamics of psychotropic medications; updated knowledge on the chronic and acute physical illnesses of late life and how they affect cognition and behaviour; a familiarity with medications used to treat chronic medical conditions, in order to evaluate their effects on behaviour and cognition and to avoid potential drug interactions with psychotropics; an expert ability to assess cognitive function and to determine the etiology of cognitive impairment; the ability to work with family systems, using extensive knowledge of community support networks and familiarity with the range of evidence-based psychiatric therapeutic modalities; the capacity to assess competence; and the capacity to deal with the multiple medical or legal issues that arise with elderly patients. Although many of these skills are not the exclusive domain of geriatric psychiatrists, this subspeciality is unique in that the assessment and management of each patient requires these skills. In Canada, geriatric psychiatry is flourishing. The Canadian Academy of Geriatric Psychiatry (CAGP) has over 190 members. The Academy hosts an annual academic meeting and provides residency training and fellowship awards. The CAGP was instrumental in developing the Canadian Coalition for Seniors’ Mental Health (CCSMH)—an organization that includes health professionals, researchers, government officials, caregivers, and seniors’ organizations. The goal of the CCSMH is to support collaborative initiatives to facilitate mental health for seniors through innovation and dissemination of best practices. Canadian geriatric psychiatrists play important roles in international organizations such as Alzheimer’s Disease Interna- tional, the International Psychogeriatric Association, and the American Association of Geriatric Psychiatry. In 1999, the CAGP cohosted and organized the ninth Congress of the International Psychogeriatric Association—arguably the largest and most successful academic geriatric psychiatry meeting to date. As Canadian geriatric psychiatrists, we hold numerous peer-reviewed research grants, publish in peer-reviewed journals, and sit on international editorial boards. The articles in this issue, covering topics related to depression, dementia, and health services, are only a small sample of our academic activities. We have organized numerous undergraduate and postgraduate training programs in psychiatry across Canada, and we have published widely on educational issues related to geriatric psychiatry (2–6).
Although we have a specialized knowledge base and skill set, successful research and educational programs, and the necessary critical mass, geriatric psychiatry has failed to receive subspecialty recognition, despite concerted attempts over the past decade. Though the Royal College of Physicians and Surgeons recognizes a need for training in geriatric psychiatry, there is no time requirement (unlike the 6-month minimum for child psychiatry), nor is there a clinical rotation mandated (7). This stands in stark contrast to the American Board of Psychiatry and Neurology, which approved subspecialty certification in geriatric psychiatry in 1988.
As the demographic imperative increases with the aging of our society, the need for geriatric psychiatry services will continue to grow. This will lead to increasing demands in an already underserviced area. Recruitment to geriatric psychiatry suffers because it tends to be an “acquired taste,” with residents recognizing their interest after clinical rotations, often late in their training. Subspecialty recognition will strengthen the awareness and the profile of geriatric psychiatry, increasing the likelihood of recruitment into the practice. It will lead to national standards and specific training requirements, improving the education of subspecialists and general psychiatrists alike. This will be advantageous not only for our profession but also for our patients.
Over time, geriatric psychiatry in Canada has matured and achieved success. It is time for the Royal College of Physicians and Surgeons to recognize this maturity and to finally approve subspecialty designation.
References
1. World Health Organization (WHO). Psychiatry of the elderly: a consensus statement. Geneva: WHO; 1996.
2. Lieff SJ, Tolomiczenko GS, Dunn LB. Effect of training and other influences on the development of career interest in geriatric psychiatry. Am J Geriatr Psychiatry 2003;11:300–8.
3. Lieff SJ, Clarke D. What factors contribute to senior residents’ interest in geriatric psychiatry? A Delphi study. Can J Psychiatry 2000;45:912–6.
4. Silver I, Cohen C, Hildebrand A, Lieff S, Rabheru K. The geriatric psychiatry curriculum in Canadian medical schools. Gerontol Geriatr Educ 1999;19:35–46.
5. Herrmann N. Mandatory training in geriatric psychiatry: can programs deliver the goods? Can J Psychiatry 1994;39:523–5.
6. Herrmann N, Shulman KI, Silver IL. Intensive early exposure to geriatric psychiatry in residency training: impact on career choice and practice. Can J Psychiatry 1992;37:549–52.
7. Royal College of Physicians and Surgeons of Canada. Objectives of training and specialty training requirements. Ottawa: Royal College of Physicians and Surgeons of Canada; 2002. Updated 2002 Oct 12. Available: http://rcpsc.medical.org/information/index.php?specialty=165for examplesubmit=select. Accessed 2003 Dec 16.
Author
1. Head, Division of Geriatric Psychiatry, Associate Professor of Psychiatry, Sunnybrook and Women’s Health Sciences Centre, University of Toronto, Toronto, Ontario.
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