‘I’m a psychogeriatrician’

In today's guest post, Claire Hilton argues that historical evidence about psychogeriatrics is crucial to understand the political, medical, social and professional factors which have shaped the specialty, drawing on her 2016 Medical History article ‘Psychogeriatrics in England: Its Route to Recognition by the Government as a Distinct Medical Specialty, c.1970–89’ (Medical History, 2016, 60, 2, 206-228) https://doi.org/10.1017/mdh.2016.4

‘I’m a psychogeriatrician’ uttered at a social event, almost always stops conversation. This was common during the formative years of the specialty of psychogeriatrics (or old age psychiatry) and remains common today. The questioner almost always implies: why would anyone want to work specifically with older people who are mentally unwell?

Psychogeriatricians in the 1970s and 1980s advocated for their patients. They fought to achieve government recognition for their specialty. Recognition enabled dedicated funding and training, and expansion of the specialty nationally and internationally. This helped to ensure that older people received evidence-based treatment for their mental illnesses. Treatment methods, at that time well established for younger people, were used infrequently for older people suffering the same illnesses. Treatment required some modification to take into account challenges associated with ageing, like frailty, risk of falls and co-existing physical illnesses. Importantly, the psychogeriatricians’ medico-psycho-social model of treatment could ameliorate problematic symptoms and behaviours, support carers, and enable older people to live in their own homes for longer, thus reducing bed use in institutions. Psychogeriatricians struggled against stereotypes of the ‘slippery slope’ of old age health expectations, lack of public and political interest in older people’s mental health, and therapeutic nihilism about treatment.

The psychogeriatricians used religious language to describe their work, such as ‘pilgrim’ and ‘crusade’. Those who discovered the rewarding nature of the work described themselves as ‘converts’. Their successors still do.

In 2015, leading psychogeriatrician Dr James Warner wrote about the ‘erosion of old age services’ (James Warner, ‘Old age psychiatry in the modern age’ British Journal of Psychiatry (2015) 207, 375–376). Erosion can be attributed to various factors, including austerity and financial constraints, ongoing under-valuing of older people, and misled political correctness about the anti-discrimination agenda. Anti-discrimination has led to the re-emergence of ‘ageless services’ in many parts of the UK, but this model of one-size-fits-all too frequently marginalises the specific needs of older people, and removes the enthusiastic staff who feel inspired to spend their careers working with them. We once again see older frail people being treated on the same ward as younger physically fit disturbed patients, and the occurrence of fractured bones when frail patients fall if accidentally pushed, an avoidable risk which the early psychogeriatricians aimed to eliminate.

Historical evidence about psychogeriatrics is crucial to understand the political, medical, social and professional factors which have shaped the specialty. This knowledge should help to avoid re-introducing risky treatment and care practices which undermine wellbeing and lead to unnecessary suffering and financial expense.

Claire Hilton