Small Talk over an Old Block
by Dr Ravivarma Rao Panirselvam, Department of Psychiatry and Mental Health, Hospital Bintulu, Sarawak and #LamanMinda Group
Our ride took a break in this valley for a moment of quiet before the task ahead. My name is Ravi and I work in Bintulu, Sarawak. This trip is part of our regular community mental health visit to a town by a tributary to the mighty Rajang River. Our mental health team cares for a region of approximately 30 000 km2 which is largely rural, loosely populated and under-accessed.
The picture above is a conjecture to mental health morbidity in rural areas which is less spoken and recognised, especially depression. Depression has often been painted as urbanite illness. While urban lifestyle and financial crunches are real, rural living has its own set of stressors. This is profound, especially on the elderly who are caught in a tide of a world once known.
Rural Sarawak is rich in tradition and community living. Communities live in a single extended unit known as the longhouse where multiple families coexist as neighbours and functional economic units. The concept of retirement in rural communities is abstract. People tend to engage in economic activities like small scale farming and craftsmanship till their health would not permit it anymore. Furthermore, Sarawakians have enjoyed a higher life expectancy than the national average.
Alas, development and progress has washed on the banks of the heartlands which has led to migration and movement. Traditional economies have hybridised into societies which bear some semblance of the past with alien features of the future.
In context of geriatric depression, subtle changes go unnoticed. Modernity brings a disease burden of its own and as physical health fails, seclusion increases. The changing fabric of society sustains the illness. The elderly who became depressed are either normalised for aging or mistaken for dementia (further mistakenly normalised). Only at times when a profound lack of self-care sets in, is when healthcare services are sought.
Upon crossing the diagnosis hurdle, our mental health team starts the real work with psychoeducation i.e. talking to the service user, the family and at times longhouse members. The discussion would stem on the nature of illness and branch into management options i.e. lifestyle changes or medications. It is crucial that we involve primary care services to follow-up on the progress of the service user as distance and lack of phone reception is a commonality rather than an exception. Psychological services are scarce but adaptations are ingenious. A noteworthy example would be a form of behavioural activation using day-to-day activities around the longhouse. Increased engagement was able to reintroduce activities, including farming, to the service user, aiding recovery and return of quality of life.
It again underpins the importance of the biopsychosocial model of management and engagement of the local community. By turning difficulties into possibilities, improvisation has enabled quality care in a place that is four hours away from the nearest hospital. It also speaks volumes on the need to have the conversation on geriatric depression, not only among service users, but society at large as it is not only treatable but curable. The elderly are our repository of wisdom and their improved quality of living will enrich all our lives. Awareness leads to empowerment, so let’s talk!
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© 2017 Volunteering and International Psychiatry Special Interest Group, all rights reserved. Reproduction by permission only.