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Geriatric Mental Health and COVID-19: An Eye-Opener to the Situation of the Arab Countries in the Middle East and North Africa Region

HIGHLIGHTS • This review provides a synopsis of the status of geriatric psychiatry in the Arab countries of the Middle and North Africa (MENA) region and narrates the mental health interventions implemented during the COVID-19 outbreak for both the general public and the geriatric population.• The mental health of the geriatric population in this part of the world is overlooked, especially during the COVID-19 pandemic. Although several measures are implemented to address mental health during the COVID-19 outbreak, these are generally insufficient in targeting the geriatric population.• An effective task force is needed to strengthen the geriatric mental health response to the COVID-19 outbreak at both national and regional levels in the Arab countries of the MENA region.


INTRODUCTION
C OVID-19 constitutes a new major global health challenge. The socioeconomic and health care impacts of this pandemic are unprecedented, with worldwide economic loss, travel restrictions, closure of business activities, social distancing, isolation and quarantine, fear of shortage of basic needs, and rapid spread of mental health problems. 1−3 The unpredictable nature of COVID-19 and its associated individual, societal, and global repercussions not only threaten one's physical health but also affects their mental health. Data from a cross-sectional study in China revealed that more than half of the surveyed participants experienced moderate-to-severe psychological distress secondary to the outbreak. 4 The distress stems from the constant fear of contracting the virus, contracting it, losing loved ones to the illness, and being socially isolated or quarantined. These factors can precipitate mental illness in those with no previous psychiatric history or exacerbate symptoms in those with a pre-existing mental illness. 5 One of the core features of COVID-19 is its predilection for infecting older adults and those with chronic underlying health conditions, resulting in higher mortality. 6 Given that older adults generally suffer a greater number and higher severity of chronic diseases as compared to the younger population, 7 one can expect that the COVID-19 outbreak will disproportionately affect the geriatric population.
In this respect, the subspecialty of geriatric psychiatry is uncharted territory. Scarce literature exists about the psychiatry of old age during pandemics. During the severe acute respiratory distress syndrome (SARS) outbreak, which occurred between 2002 and 2004, a mental health toll particularly affected the geriatric population. A case study conducted in Hong Kong in 2003 attributed 22 suicide events to be "SARS-related," with the mean age of attempters being 74.9 years. Disease burden among the elderly with long-term illness contributed as a significant factor for suicide. 8 Another cross-sectional study, also conducted in Hong Kong, showed an increase in suicide rates in older adults during the year of the outbreak; this was particularly significant in females above the age of 65 years. 9 A lingering elevation in rates of elderly suicide was observed until 2004. 10 It is essential to recognize how the impact of the COVID-19 outbreak on mental health varies around the world, particularly in low-and middle-income countries. 11 In the Arab countries of the Middle East and North Africa (MENA) region, the percentage of the population over the age of 65 is estimated at 5.1% (of a total population of 449 million). 12 By 2050, the proportion of older adults is predicted to increase to 19%. 13 Health care systems in the region have so far ignored the needs of older adults and tend to heavily rely on family or community-based social support. 14 Few programs in the Arab countries of the MENA region, governmental, community-based, or initiated by private sectors, have tried to meet the needs and overcome the challenges of the geriatric population. 14,15 Geriatric mental health, on the other hand, is frequently overlooked. 16 This stems from a lack of awareness about the symptoms of mental illness in the elderly and a dismissive belief that affected mental health is a normal part of the aging process. 17 Even though psychiatry of the old age constitutes one of the priority areas for health interventions in the Arab countries of the MENA region, 17 little is known about the state of geriatric mental health during the COVID-19 outbreak in this part of the world. Therefore, throughout this evolving situation, and as a group of Arab early-career psychiatrists, we provide a state-of-the-art review of the status of geriatric psychiatry in the Arab region during the COVID-19 outbreak. Close to the frontlines of this pandemic and being aware of the needs of this vulnerable population, we describe the status of older adults in this part of the world. We then shed light on the general and targeted mental health interventions implemented during the COVID-19 outbreak. Finally, we derive targeted interventions for implementation in the Arab countries of the MENA region.

METHODS
We invited thirteen early-career psychiatrists from the Arab countries of the MENA region to share information related to geriatric psychiatry and COVID-19 in their respective nations. We elected for early-career rather than mid-career or late-career psychiatrists to provide a new perspective about the situation of geriatric psychiatry in this part of the world and to add emphasis on the importance of early-careers, the torchbearer of future psychiatry. 18 Each member of the team provided information about the mental health measures taken in their country during the COVID-19 outbreak, with a particular focus on interventions directed towards the geriatric population. This was done using a semi-structured guide, presented in Supplementary Table 1. All members of the team carried out their search using the governmental ministry of health websites of their respective nations, along with local or international electronic newspapers and magazines discussing the topic of geriatric psychiatry during the COVID-19 outbreak.
To complement this search, we also checked different search engines (PubMed, Medline, and Scopus), from inception until April 5, 2020, for references about the status of the COVID-19 outbreak and geriatric psychiatry in the MENA region. Terms used in the search included "COVID-19," "coronavirus," "SARS-COV-2," "geriatrics," "elderly," "aging," "mental health," "psychological distress," "coping style," "social support," and "psychiatric disorders." We reviewed relevant references for the articles of interest and only included those published in English.
Discussion between the authors of the manuscript occurred via email. Ethical permission was not sought as there was no direct involvement of human participants and data used were already available in the public domain.

Status of Geriatric Mental Health in the Arab Countries of the MENA Region
Few studies assessed the mental health status of the geriatric population in the Arab countries of the MENA region. These studies are mainly clustered in Egypt, Lebanon, Kingdom of Saudi Arabia (KSA), and the United Arab Emirates (UAE), and mostly tackle old age depression. Overall, research in this part of the world indicates a high prevalence of depression among the geriatric population, with prevalence numbers varying between 10% and 46%. 19−26 Depressive symptoms are also common within sub-populations of older adults, reaching a prevalence of 46% in those with Parkinson's disease 27 and 57% to 86% in dementia of Alzheimer's type and vascular dementia, respectively. 28 Most studies identified living alone, 22−25 living in a nursing home, 25,29,30 illiteracy, 25,29,30 and having chronic diseases 19,24,25 to be associated with geriatric depression.
This comes on top of a general lack of services directed towards geriatric mental health in the Arab region. Looking at the status of different countries, one can cluster them into three main categories. Some nations have limited exposure to geriatric psychiatry, such as Algeria, Libya, Sudan, and Syria. For instance, Sudan has no geriatricians or geriatric mental health clinics; most of the limited psychiatric services are restricted to the capital and major cities. Similarly, in Syria, geriatric medicine remains a foreign discipline taught along with the endocrinology and nutritional disorders module of medical schools. Other nations have some resources for geriatric medicine, but minimally available expertise. These include Jordan, Lebanon, Morocco, Oman, KSA, and Tunisia. Jordan has less than ten geriatricians whereas Lebanon encompasses about twenty specialists, of whom two are geriatric psychiatrists. In addition, the Alzheimer's Association Lebanon constitutes one of the oldest and most active Alzheimer's associations in the region. In Morocco, geriatrics became a field of study for medical school graduates a few years ago and geriatric psychiatry is currently part of the curriculum of trainees. Oman is starting to witness a rise in the field, with newly established geriatric psychiatry clinics in two tertiary hospitals, run by five geriatric psychiatrists. The Oman Al Zahimer Association for dementia has also been providing support for patients with dementia and their caregivers throughout the country. In comparison, while there are no clinics dedicated to psychogeriatrics in Tunisia, except for some specialized units in dementia, a university diploma and a research unit exist at the faculty of medicine of Monastir in the center of the country. Geriatric psychiatry services also remain limited in the UAE. Lastly, very few nations have developed extensive resources and services allocated to geriatric psychiatry. In Egypt, most of the psychiatry departments already have or are currently establishing their psychogeriatric section with outpatient clinics and memory clinics. Geriatric psychiatry is currently one of the requirements in many of those training programs. The Egyptian Alzheimer Society has been leading the field and spreading awareness for years now. Alternatively, geriatric psychiatric services in Qatar are provided through different models, including outpatient clinics, specialized memory clinics, consultations on the medical floors of general hospitals, and via residential and home visits for people who cannot reach out. The service has been growing significantly in recent years, particularly following the launching of Qatar National Dementia Plan 2018−2022 and plans for``Healthy Ageing" in the country. 31,32 Table 1 summarizes the characteristics of the geriatric population and geriatric mental health training in each of the represented thirteen countries. 33

Status of Geriatric Mental Health During the COVID-19 Outbreak in the Arab Countries of the MENA Region
Since the start of the COVID-19 outbreak, the Arab countries of the MENA region have implemented several measures to improve mental health outcomes during this pandemic (Table 2 42−61 ). These include followup on patients via videoconference or phone calls. Most generated educational material in the form of videos, posters, or pamphlets released on social media outlets. Many nations also introduced hotline numbers to provide counseling and support. These measures, mostly directed towards the general population, have failed to cater to the needs of the geriatric population. Targeted interventions have been initiated only in countries with good resources and expertise in the field. In Egypt, the General Secretariat for Mental Health and Addiction Treatment launched social media campaigns tackling stress during the outbreak, with a focus on vulnerable populations, including the older adults. In KSA, alternatively, the National Center for Mental Health Promotion has been providing daily support for older adults and their caregivers, via communication at a hotline number and targeted learning material released on social media outlets. In Qatar, geriatric mental health services have shifted to telepsychiatry. Lastly, Jordan and Oman have initiated a home delivery system of psychotropics for the geriatric

DISCUSSION
In this part of the world, geriatrics and geriatric psychiatry remain a novel and, at times, an exotic field with minimal exposure or resources. It is a relatively new domain for graduates from medical schools in the Arab region. It lacks the glamour of other specialties, and its limited training opportunities make it unappealing.
The needs of this vulnerable population should be taken into consideration, particularly during the COVID-19 situation. In the Arab countries of the MENA region, changing family dynamics secondary to labor opportunities have caused a shift in family structures, with grandparents more commonly taking care of grandchildren, while parents work abroad. Should grandparents become infected or succumb to the illness, the implications on their extended families will be profound. 11 Second, self-isolation during the COVID-19 outbreak can severely affect older adults, whose only social contact is out-of-the home, such as at community centers and places of worship. Also, increasing numbers of the elderly in the low-and middle-income countries are being cared for in nursing homes, which often are unregulated and have limited services. 66 Those who attend nursing homes and lost face-to-face contact with their family members, those who do not have spouses, family, or friends, and those who rely on the support of voluntary services or social care, are all equally affected. 67,68 Since many healthcare systems of the MENA region face severe limitations and are unlikely able to provide the needed care for all COVID-19 patients, a disproportionate number of those are expected to be older. Further marginalization of the geriatric population would ensue. 11 Subsequently, self-isolation among the elderly would become associated with considerable morbidity and mortality secondary to cardiovascular and neurocognitive complications 69 and mental health problems. 69,70 During the COVID-19 outbreak, five organizations in China, including the Chinese Society of Geriatric about mental health in person and via social media outlets. These tackle the anxiety and panic reactions that are expected to arise during the COVID-19 pandemic.
Delivering online webinars targeting mental health during the pandemic, sponsored by the Abu Dhabi Health Services Company.
Arranging video conference calls to provide mental health support by a dedicated team of psychologists. These are available 24/7 (UAE's VPS Healthcare Organization has joined hands with a Psycho-social rehabilitation center based in India to make this possible).

Yes
Yes Psychiatry, promptly released expert recommendations on how to provide mental health support for the geriatric population. 68 Similarly, the international dementia experts and Alzheimer's Disease International called for urgent support for people living with dementia and their supporters. 71 Besides, the role played by older adults in developing and maintaining strategies for disaster preparedness, response, and recovery has previously shown to be efficacious. 72 In the Arab countries of the MENA region, guidance around this issue remains, however, unaddressed. An age perspective should be included in the development of any national or regional planning for COVID-19, with recommendations targeting the needs of older adults. As an attempt to invite healthcare workers, policymakers, and stakeholders to look further into the needs of this population, we provide a comprehensive list of recommendations ( Table 4) that aim to enhance the general status of geriatric mental health in the Arab region, and particularly during the COVID-19 outbreak. In the short-term, the focus should be on raising awareness about the importance of mental health in the geriatric population and providing appropriate resources for the elderly (whether by giving focused training to primary and mental health physicians or via employing innovative tools such as telepsychiatry and hotlines). Treatment measures should follow a multidisciplinary approach within a collaborative care model. Long-term recommendations should target improving geriatric medical training and allocating funds for the specific needs of older adults.

CONCLUSION
In earlier epidemics, such as SARS, the impact on the mental health of the geriatric population was found to be detrimental. During the COVID-19

Short-Term Recommendations
Raising awareness -About the importance of mental health in the geriatric population, counteracting the erroneous perception that mental illness is an expected outcome of aging. -About the available mental health services provided to the geriatric population.
-Against stigmatizing media coverage that marginalizes the geriatric population as the "sacrifice age group" during the COVID-19 outbreak. -About the importance of social distancing between family members and older adults, yet maintaining contact via other tools (phone calls, internet, etc.). Providing and improving mental health services -Via training mental health teams and primary care clinicians in providing essential mental health care for older adults. -Via teaching targeted psychological first aid to nonspecialized clinicians. -Via offering individual and group counseling to older adults in need.
-Via catering for specific days dedicated to older adult visits and follow-ups at geriatric clinics in the health care centers and hospitals. -Via using telepsychiatry to assess and treat geriatric mental health problems during isolation. At homes or nursing sites where telepsychiatry is not affordable, service teams could provide support and behavioral management through telephone hotlines. -Via creating mobile crisis teams and liaison services to reach out to those in rural areas. Implementing measures -Adequate documentation and appropriate use of mental health assessment tools to allow better assessment of symptoms, treatment interventions, and their efficacy. -Collaborative care between health care providers (geriatricians, geriatric psychiatrists, neurologists, primary health care physicians, psychologists, nutritionists, and social workers), patients, families, caregivers, and nursing home administrators to provide the best outcomes for the geriatric population. -Close follow-up on the status of governmental and non-governmental nursing homes to maintain an adequate quality of care and hygienic measures.

Long-Term Recommendations
-Creating or expanding geriatric medicine training positions.
-Establishing appropriate and adequate exposure to the geriatric population as part of a mandatory rotation in all psychiatry training programs.
-Providing training for clinicians in primary care in the mental health of older adults.
-Recruiting more specialists in the field, including geriatricians and geriatric psychiatrists.
-Establishing daycare facilities and nursing homes for older adults with mental health problems.
-Allocating part of the governmental and non-governmental funds towards the needs of the geriatric population.
-Decentralizing resources away from large cities and capitals to ensure service availability for all people.
-Developing a national policy that protects the geriatric population's general health and mental health.
outbreak, vulnerable populations, particularly older adults, remain at high risk for the development and exacerbation of mental health problems. This is of high concern in the Arab countries of the MENA region, where insufficient attention has been so far paid to the geriatric population. Mental health professionals, medical practitioners, stakeholders, health policymakers, and governmental and non-governmental organizations should collaborate to develop an effective task force that strengthens the geriatric mental health response to the COVID-19 pandemic at both national and regional levels.

AUTHOR CONTRIBUTIONS
SEH conceptualized the study. SEH and MAC wrote the manuscript and interpreted the information gathered from other authors. MAC did the literature review of the topic. MN and AL helped in recruiting early-career psychiatrists from the different Arab countries. SEH, MN, DA, AA, SAS, MA, NA, CA, LB, AME, AL, AR, and MS provided relevant information for the review about their respective countries. SEH, MAC, and HAS supervised the work. All authors proofread the manuscript and approved it in its final version.