Mental healthcare in South Korea

Abstract

The Korean peninsula is located between China and Japan. After the Second World War, the Republic of Korea was established in the southern half of the Korean peninsula. South Korea has a total area of 98 480 km² and a population of 48 598 175 (July 2004 estimate). The per capita gross domestic product (GDP), in terms of purchasing power parity, is US$17 700 (2003 estimate) (Central Intelligence Agency, 2004). The illiteracy rate (among those aged over 15 years) is 1.9% (0.7% for males and 3% for females) (2003 estimate). Life expectancy at birth is 75.6 years (72.0 years for males and 79.5 years for females) and the infant mortality rate is 7.2 per 1000 births (2004 estimate). The unemployment rate is 3.4% (2003 estimate). The proportion of the population aged 65 and over is currently 8.7% (2004 estimate) (Korea National Statistics Office, 2003). Over 40% of the total Korean population (i.e. some 20 million) lives in Seoul and its vicinity. South Korea is highly urbanised and modernised. Besides central government, local government is based on seven metropolitan cities and nine provinces.

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Mental health services

There is one hospital bed for every 148 citizens and one psychiatric bed for every 1446. There is one physician for 830 citizens and one psychiatrist for every 19 500 (2002 estimates).

The basic healthcare needs of the Korean population are covered by universal public health insurance, funded by premiums, not taxes. This is compulsory, and there is no private health insurance. None the less, the private sector accounts for approximately 90% of mental health services, as there are too few public facilities. However, the government is responsible for free nationwide healthcare funded by taxes for the poor and aged. Thanks to an active community mental health movement in the public and private sector of psychiatry, since 1995, 242 public health centres nationwide have registered to take care of people with mental illness, including elderly people with dementia or stroke. In 2002, there were 989 specialist mental health facilities in South Korea: 46 community mental health centres, 66 social rehabilitation facilities, 74 mental hospitals, 207 general hospitals with psychiatric out-patient departments, 541 psychiatric clinics and 55 nursing homes.

Table 1 shows the progress in the public mental health project run by the Korean government. Both community and institutional care programmes provide long-term care. Home help services and delivered meals, adult day care, short-stay and respite care and a visiting nursing programme are also available to people with mental illnesses, including elderly people with a mental disability. Table 1 shows that care capacity is being substantially increased. The proportion of the population in need of community care who could be catered for by the maximum community care capacity will increase from 4.7% in 2003 to 72.2% in 2011, and the equivalent proportion of those in need of institutional care from 30.2% in 2003 to 71.0% in 2011 (see Table 1).

Table 1. Projected estimates of the provision for community and institutional mental healthcare in Korea.

Year	2003	2005	2007	2009	2011
Community care
Number of home help centres	120	470	1 020	1 770	2 769
Number of day care centres	166	416	866	1 516	2 561
Number of short-term care centres	32	131	356	681	1 079
Total number of community care facilities	318	1 017	2 242	3 967	6 409
Maximum community care capacity, n	15 200	52 700	114 700	200 700	319 930
Number of patients who need community care	320 974	353 080	387 528	416 319	442 925
Community care capacity rate (%)	4.7	14.9	29.6	48.2	72.2
Inustitutional care
Number of residential homes (capacity)	161 (11 270)	245 (17 150)	325 (22 750)	405 (28 350)	488 (34 160)
Number of nursing homes (capacity)	120 (8 400)	192 (13 440)	264 (18 480)	355 (24 850)	454 (31 780)
Number of dementia care hospitals (capacity)	37 (3 852)	51 (4 952)	65 (6 052)	79 (7 152)	93 (8 252)
Total number of institutional care facilities	318	488	654	839	1 035
Maximum institutional care capacity	23 522	35 542	47 282	60 352	74 192
Number of patients who need institutional care	77 836	84 838	92 347	98 624	104 423
Institutional care capacity rate (%)	30.2	41.9	51.2	61.2	71.0

Source: Ministry of Health and Welfare (2003, personal communication).

To meet the demand for institutional care arising from the increasing numbers of cases of dementia and stroke, special units in nursing homes and dementia care hospitals are being constructed all over South Korea.

A multidisciplinary community-oriented approach has been adopted and close working relationships have been maintained with various professionals caring for people with mental illnesses. In general, each team has a catchment population of about 50 000–200 000, which would include some 3500–14 000 people aged 65 and over. The staff usually comprise one consultant psychiatrist (generally part-time), one community psychiatric nurse, one social worker or psychologist and several volunteers. They draw on a variety of community resources in devising the most effective care pathway for people with mental illnesses and focus on enabling them to stay longer in their own homes. They have responsibility for registration, case management and education. Some of them run day care programmes for schizophrenia, alcohol dependence or dementia. The public sector has been more active in home-visiting outreach activities, while the private sector has been promoting day care rehabilitation. These movements in South Korea have been instrumental in developing infrastructure and providing mental health services.

Psychiatric treatments

The predominance of the private sector and the relatively generous reimbursement of public health insurance have made Korea a large and early market for novel drugs in psychiatry, although reimbursement for novel drugs has now become subject to much stricter regulation. Atypical antipsychotics and novel antidepressants are much more widely used in South Korea than are traditional antipsychotics and tricyclic antidepressants. Electroconvulsive therapy also has been frequently used; there is no special limitation on its use. Psychoanalysis, psychodynamic psychotherapy, cognitive–behavioural therapy, group therapy and even hypnosis are applied on in-patient wards and out-patient clinics in psychiatry.

Training

Basic undergraduate training in psychiatry forms part of the curriculum in medical school. Postgraduate training comprises a 4-year residency in psychiatry, in which both the theoretical and the clinical aspects of psychiatry are covered. This leads to the psychiatric board examination. Training programmes are accredited under the auspices of the Korean Neuropsychiatric Association, which is also the medical body that deals with all academic issues.

Epidemiological issues

There have been several community-based epidemiological studies on the prevalence of mental disorder in South Korea (Cho et al, 1998; Suh et al, 1999a, 2003; Suh & Shah, 2001). Epidemiological data on the prevalence of mental health problems help to determine the need for care. Dementia and depression are the most common mental disorders and the most severe public health problem, especially in the older population. Korean reports have been comparable to those of Western studies. Suh et al (2003) interviewed 1037 people aged 65 and over, and found a prevalence of dementia of 6.6% (Alzheimer’s disease 4.2%, vascular dementia 2.4%). A nationwide survey examined the prevalence of depressive symptoms in the Korean population. The prevalence rates using a cut-off score of 16/17 on the CES-D (Center for the Epidemiologic Study of Depression) scale were 23.1% of male adults, 27.4% of female adults and 24.3% of the elderly population (Cho et al, 1998; Suh et al, 1999a). A community-based survey reported a prevalence of ‘the wish to die’ within last 2 weeks among elderly respondents of 14.6% (Suh et al, 1999b).

To meet the demand for institutional care arising from the increasing numbers of cases of dementia and stroke, special units in nursing homes and dementia care hospitals are being constructed all over South Korea.

A total of 788 000 persons, equivalent to 21% of the South Korean elderly population, were in need of long-term care in 2001. Of these, at least 74 000 needed institutional care, while the remainder required community care. The number of patients with dementia and disturbed instrumental activities of daily living has been estimated at 186 000, and this group will require institutional care at some point (Sunwoo, 2001).

Problems in mental healthcare in South Korea

There are several problems in mental healthcare in South Korea. First, medical, psychiatric and social welfare services are separate, which means that integrated care is not available. This separation originated from an artificial distinction between ‘treatment’ and ‘care’. Second, sub-acute care facilities are too scanty: there are generally only acute care and chronic care facilities. Differentiation of function in facilities is necessary, for example ‘hostel’ for mild cases and ‘nursing home’ for severe cases. Third, public care facilities are too few (less than 10% of the overall mental healthcare provision). Most facilities are private and this leads to frequent conflict between consumers, government and suppliers. However, the Korean government has substantially increased its expenditure on healthcare and social welfare to meet the unmet need. It is also actively considering the adoption of a long-term care insurance system, similar to those that have been adopted in Germany and Japan.

Medical, psychiatric and social welfare services are separate, which means that integrated care is not available. This separation originated from an artificial distinction between ‘treatment’ and ‘care’.

Conclusion

The private sector provides approximately 90% of mental health services in South Korea. These services are in short supply for the population, despite the relatively high number of psychiatrists. Thanks to an active community mental health movement in the public and private sectors of psychiatry and the long-term care plan being implemented by the Ministry of Health and Welfare, better care provision is expected. Although services have actively been trying to move away from institutionalisation to community-based care, the inadequate number of fully qualified community mental health professionals, prejudice towards mental illnesses among the general population and less active participation of board-certified psychiatrists make this move difficult. However, a large investment in infrastructure, the development of programmes for community care, upgraded training and active research will lead to a more modern, community-based, multidisciplinary approach to healthcare in South Korea.