Hi XXXXXXX

Substance abuse in the elderly is an often underestimated problem. Especially, in deprived communities, substance abuse is highly prevalent among the elderly. Unfortunately, it often goes undetected and unattended to.

In the case scenario, you are the consulting psychologist of a large retirement community and you are beginning to realize that many of the elderly clients are depressed and may be abusing a variety of substances.

Firstly, in this scenario, the problem seems to be more that just substance abuse. In fact, the substance abuse may be just the tip of the iceberg or in other words, merely one of the outward manifestations of more serious underlying issues.

Since it is a retirement community, it is very likely that there could be economic and social deprivation and isolation. This implies that the access to healthcare facilities is also likely to be poor. This is evident by the fact that many of them have not had their prescriptions changed for years together. So, a combination of factors such as poor socio-economic status, isolation, multiple health problems (which is common in the elderly age group) and the lack of adequate medical facilities, could be major underlying causes for the high prevalence of depression in this community. The substance abuse is very likely to be a coping mechanism in the midst of these adversities. That is why I had mentioned that the substance abuse is probably just the tip of the iceberg.

Now, how do you go about tackling this complex scenario?

Well, the first step would be to make a detailed assessment about the extent and severity of the problem, so that an appropriate management plan can be drawn. This assessment should include an in-depth analysis into various factors like:

-     Prevalence and patterns of substance abuse
-     Morbidity patterns, especially the psychiatric morbidity pattern in the community
-     Socio-demographic profile of the community
-     Current healthcare access pathways and the effectiveness / levels of utilization of the same
-     Existing social and cultural support structure – for example NGOs, religious organizations and support groups, etc.

Once you have a clear idea about the extent and severity of the substance abuse problem and also about all the other associated contributing factors, then the next step would be to formulate a management plan. Since resources are likely to be scarce in this fringe population, the management plan should first see how to effectively make use of the existing resources.

You should liaise and work together with the primary health centres and GPs catering to this area. You can formulate a brief assessment questionnaire which will enable healthcare provides or social / community workers to easily screen and detect people who are in need of professional help. You can put in place a referral system, where complicated cases, which require specialist care, can be referred to the nearest psychiatrist. Since, it is unlikely that the referring psychiatrist would have the time and resource to be able to deal with every case, you should probably take up the major role is assessing, screening and managing uncomplicated cases. You should also liase with the psychiatrist in following-up and monitoring the more the complex patients who are under intensive treatment from the psychiatrist.

Local bodies and NGO /religious groups can be involved actively in order to be more effective in delivering better community services. For example, providing better social support, better recreational facilities and improving the overall quality of life can all go a long way in preventing depression and substance abuse problems.

Last but not the least, it is important to keep following up and monitoring your interventions – 1) to ensure that the planned strategies are being implemented, and 2) to see in further improvements or positive changes can be made.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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