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About the Editor-in-Chief
HOWARD S. FRIEDMAN is Distinguished Professor
of Psychology at the University of California, River-
side. He also holds an adjunct appointment as Clini-
cal Professor at the University of California, San
Diego Medical School. Dr. Friedman attended Yale
University, graduating magna cum laude with honors
in psychology. He was awarded a National Science
Foundation graduate fellowship at Harvard Univer-
sity, where he received his Ph.D.
Professor Friedman is a thrice-elected Fellow of the
American Psychological Association and an elected
Fellow of the Society of Behavioral Medicine and the
American Association for the Advancement of Sci-
ence (AAAS). Friedman is author of many influential
scientific articles in leading journals and was named
a ‘‘most-cited psychologist’’ by the publishers of the
Social Science Citation Index. His books include two
textbooks, Health Psychology and Personality; three
edited scholarly volumes; and the authored compre-
hensive analysis titled The Self-Healing Personality.
Dr. Friedman’s research centers around the relations
of mental and physical health, with a special focus
on expressive style. He has taught undergraduates,
graduate students, medical students, and postdocs.
Professor Friedman has received the career Out-
standing Contributions to Health Psychology Award
from the Health Psychology Division of the Ameri-
can Psychological Association. He also received the
Distinguished Teaching Award from the University of
California, Riverside, and the Outstanding Teacher
Award from the Western Psychological Association.
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Preface
A number of scientific and intellectual trends have
converged to change our understanding of mental
health. Conceptions of mental health and mental dis-
orders have broadened significantly to take into ac-
count new knowledge about the genetic, biological,
developmental, social, societal, and cultural nature of
human beings. Our award-winning Encyclopedia of
Mental Health was the first to bring together these
emerging trends in one resource, and now the contri-
butions primarily relevant to assessment and to the
mental disorders are being made more accessible to
those who desire a more concise and focused refer-
ence work.
What are these mental health trends affecting our
understanding of the disorders? First, our under-
standing has moved well beyond the artificial nature–
nurture dichotomy. We know more and more about
the biological underpinnings of mental states and
behavior, but we also better understand how these
biological tendencies unfold in a family, social, and
cultural environment. Second, we have moved be-
yond the old ‘‘mental’’ versus ‘‘physical’’ (‘‘mind ver-
sus body’’) dichotomies. To a greater extent than pre-
viously imagined, there is a strong reciprocal relation
between our health and activity and our cognitions,
moods, and mental well-being. Third, the experts in-
creasingly recognize the complementary importance
of prevention and treatment. A simple model of treat-
ing mental ‘‘disease’’ is often ultimately futile without
associated prevention efforts, yet prevention cannot
sensibly ignore the need for efficacious treatments.
Fourth, we now emphasize primary mentalhealth pro-
motion—the structural, environmental, family, and
cultural context of mental health. Fifth, the best schol-
ars now recognize meaningful variations across ages,
genders, cultures, families, and societies. That is, to
understand fully and improve significantly a person’s
mental health, we need to know not only about that
person’s biological and personal makeup, but also
about his or her age, family, work, and position in
society.
CONTENTS
This volume on mental disorders thus encompasses
various levels of analysis, from the molecular and bio-
logical, through the social and family, to the cultural.
We have therefore included coverage of key topics not
traditionally found in such a reference work. We of
course include topics such as clinical assessment, psy-
choanalysis, brain neuroimaging, and family therapy.
But we also examine couples therapy, support groups,
and assessment of mental health in older adults. Also
of note is that methodological issues receive atten-
tion throughout, including important chapters on
nontraditional approaches to classifying mental dis-
orders, and on standards of psychotherapy.
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For example, take a look at the article ‘‘Hypnosis and
the Psychological Unconscious.’’
DISTINGUISHED SCHOLARS
With the assistance of the outstanding editorial board,
we have secured contributions by the most distin-
guished scholars and practitioners. Many are found-
ers of their fields, and they are justly famous. But some
contributors represent the brilliant new generation of
mental health scholars. I have encouraged the con-
tributors to write about what is most important. We
thus have a reference work that is rooted in the pres-
ent and looking toward the future, rather than bogged
down in obsolete notions and topics. Emphasis has
been placed on clarity and accessibility.
Howard S. Friedman
Stress is increasingly recognized as a complex in-
teraction of the person, the environment, the social
support structure, and the culture. Thus, many of our
articles deal with the mental health aspects of such
topics as coping with stress, as well as social support
and community mental health.
Aside from the striking breakthroughs at the ge-
netic and molecular levels, perhaps the greatest cur-
rent interest is in the family and developmental con-
text for mental health and mental impairment. We
include a truly exceptional discussion of various rele-
vant issues, including expert articles on childhood
abuse, couples therapy, domestic violence therapy,
and family therapy. Such articles should certainly be
of value to anyone involved with the mental health of
children and families.
Finally, we have not neglected those fascinating
topics usually would not be considered psychiatric pa-
thology but seem integral to understanding therapy.
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How to Use This Reference
Assessment and Therapy is intended for use by
students, research professionals, and practicing clini-
cians. Each article serves as a comprehensive overview
of a given area, providing both breadth of coverage
for students and depth of coverage for research and
clinical professionals. We have designed this reference
with the following features for maximum accessibility
for all readers.
Articles are arranged alphabetically by subject. Be-
cause the reader’s topic of interest may be listed under
a broader article title, we encourage use of the Index
for access to a subject area, rather than use of the
Table of Contents alone. Because a topic of study in
mental health is often applicable to more than one ar-
ticle, the Index provides a complete listing of where a
subject is covered and in what context.
Each article contains an outline, a glossary, cross-
references, and a bibliography. The outline allows a
quick scan of the major areas discussed within each
article. The glossary contains terms that may be un-
familiar to the reader, with each term defined in the
context of its use in that article. Thus, a term may ap-
pear in the glossary for another article defined in a
slightly different manner or with a subtle nuance spe-
cific to that article. For clarity, we have allowed these
differences in definition to remain so that the terms are
defined relative to the context of the particular article.
The articles have been cross-referenced to other re-
lated articles. Cross-references are found at the first or
predominant mention of a subject area covered else-
where. Cross-references will always appear at the end
of a paragraph. Where multiple cross-referencesapply
to a single paragraph, the cross-references are listed in
alphabetical order. We encourage readers to use the
cross-references to locate other articles that will pro-
vide more detailed information about a subject.
The Bibliography lists recent secondary sources to
aid the reader in locating more detailed or technical
information. Review articles and research articles that
are considered of primary importance to the under-
standing of a given subject area are also listed. Bibli-
ographies are not intended to provide a full reference
listing of all material covered in the context of a given
article, but are provided as guides to further reading.
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Assessment of Mental Health
in Older Adults
Carolyn M. Aldwin and Michael R. Levenson
University of California, Davis
I. Heterogeneity in Older Populations
II. Differentiating between Mental and Physical
Health Problems
III. Assessing Factors Affecting Mental
and Physical Health
IV. Assessing Positive Mental Health
V. Summary
Age Effects
Statistical relationships due solely to
the effect of chronological age.
Cohort Effects
Statistical relationships due primar-
ily to the effect of year of birth, for example, hav-
ing lived through a particular historical era at a spe-
cific age.
Discriminant Validity
The degree to which an as-
sessment discriminates between groups and/or shows
differential patterns of correlations with different out-
comes, for example, the personality trait of hostility
should predict anger and resentment better than anxi-
ety or depression.
Ecological Validity
How well an assessment applies
to or reflects the experience of the particular sample
under study.
Internal Reliability
The cross-item consistency of a
scale, that is, whether all items in the scale assess the
same construct.
Period Effects
Statistical relationships due primar-
ily to time of measurement effects.
Predictive Validity
The degree to which an assess-
ment predicts an outcome of some sort, generally be-
havior (e.g., self-reported symptoms).
Sequential Analyses
Statistical analyseswhichcon-
trast age, cohort, and period effects.
ASSESSMENT OF MENTAL HEALTH processes in
the elderly can be particularly challenging, in part due
to the fact that many assessment instruments were de-
veloped on younger populations and may not provide
as accurate a picture in older populations, who vary
greatly in their levels of cognitive, sensory, and motor
abilities. In addition, many physical and mental ill-
nesses in late life can present similar symptoms, and
differentiating between the two is the focus of much
of the assessment research in late life. Finally, the el-
derly may be less likely to disclose certain types of
problems, and thus special techniques may be neces-
sary to assess sources of psychological distress,includ-
ing substance abuse and life events. However, less is
known about what constitutes positive mental health
in late life.
I. HETEROGENEITY
IN OLDER POPULATIONS
A. Age Influences on Validity
and Reliability
As a developmental stage, late life encompasses more
than 45 years, from roughly ages 65 to 110. Not sur-
prisingly, there is an extraordinary amount of hetero-
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fonts. In addition, we have found that scantron sheets
which use relatively pale type faces with poor contrast
(e.g., lavender script on cream-colored paper) are con-
traindicated with elders who have acuity problems.
Individuals with motor impairments, such as trem-
ors associated with Parkinson’s disease or severe ar-
thritis in the hands or wrists, may have difficulty in
filling out questionnaires, and will require longer pe-
riods of time to complete them. For elders with severe
forms of these illnesses, scantron forms are virtually
impossible. Some researchers have switched to com-
puter presentations of instruments which can aid in
overcoming such sensory and motor deficits.
In general, we have found that frail elders do best
in interviews in which the required responses to ques-
tions are available in both verbal and visual forms. If
Likert scales are necessary for some instruments, then
response cards, written in large fonts, which elders
can hold and point to responses, are very helpful.
Given that cognitively impaired elders often have dif-
ficulty in switching tasks, changing response cards is a
good way of signaling that one task is done and that
attention needs to be refocused on another.
However, interviews conducted in home settings
may pose a special problem in assessing the elderly. In
our experience, it is very difficult to interview just one
member of an elderly dyad, especially in long-term
married couples. Such couples may learn to compen-
sate for memory problems by consulting with each
other, and typically the non-target spouse will re-
spond to questions, making accurate assessment of the
target individual problematic. Thus, we have found it
necessary to physically separate couples, either by giv-
ing the non-target elder an instrument to complete in
another room, or by using pairs of interviewers to
conduct simultaneous interviews, again in separate
rooms.
B. Cohort Influences on Validity
Gerontologists distinguish among age, cohort, and
period effects. In general, age effects are those which
are solely due to an individual’s chronological age, co-
hort effects refer to historical impacts reflected in a
person’s birth year or events experienced by a group
of peers (e.g., the Depression), and period effects refer
to larger social influences at the time of measurement.
Neither cross-sectional nor longitudinal designs can
adequately differentiate among these three types of ef-
fects, and only sequential designs, which follow mul-
geneity in this population. Some elders are phys-
ically and cognitively very healthy; others develop
disabling chronic illnesses quite early on. Thus, it is
often very difficult to make generalizations about ‘‘the
elderly.’’ Not surprisingly, gerontologists have subdi-
vided this developmental stage into three groups: the
young-old, whose ages range from 65 to 79; the old-
old (80–99); and the oldest-old, or centenarians. Oth-
ers differentiate between optimal aging, in which there
is little decrement or even improvement in some func-
tions; normal aging, in which there are some decre-
ments for which the elderly can readily compensate to
maintain adequate psychosocial functioning; and im-
paired aging, marked by declines in physical and cog-
nitive function.
Thus, it is very important to understand the posi-
tion along these continua of the elder or sample of el-
ders to be assessed. In general, in the United States,
the young-old are relatively healthy and it is likely
that assessment techniques used in younger popula-
tions are quite adequate for this population. Indeed, if
one attempts to use instruments developed for im-
paired elders in the ordinary young-old population,
one rapidly runs into ceiling effects—nearly all elders
will score in the top range, rendering criteria for pre-
dictive and discriminant validity nearly useless. In
other words, if there is no variance on an instrument,
it cannot be used to correlate with other measures or
to distinguish between groups.
In contrast, for frail elders, who are more likely to
be in the old-old age group, the use of standard instru-
ments may pose a problem in both the reliability and
validity of the data. Cognitively impaired elders may
become confused when confronted with typical Likert
scaling, and dichotomously scaled instruments may
have more reliability and validity. (We have found that
even elders in good condition generally dislike and
mistrust the Procrustean bed of fixed response for-
mats, and often need to be cajoled into translating
their phenomenological experience into admittedlyar-
bitrary numbers.) In addition, frail elders may have
poor attention spans, requiring the administration of
brief forms of standard instruments and/or multiple
testing sessions over several days. Although elders in
general respond as accurately on surveys as younger
populations, it is unlikely that cognitively impaired el-
ders can do so, and interviews are more likely to yield
valid information.
Elders with visual impairments may have difficulty
in reading questionnaires, requiring the use of larger
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tiple cohorts over different periods, can adequately
differentiate these three types of effects. For any given
effect to be accurately attributed to age, one must
demonstrate that individuals of a given age are more
likely to exhibit a particular response, regardless of
what cohort they are in or the year in which they are
assessed.
Age, cohort, and period effects also have implica-
tions for the validity of assessment instruments. For
example, the validity of instruments used in older pop-
ulations may be affected by cohort differences in lan-
guage use and expression, a problem that has received
relatively little attention in the assessment literature.
One must be sensitive to whether the language used in
any particular inventory is appropriate to the popu-
lation under study. Indeed, the language used in older
instruments is often more relevant to that used by
older cohorts. For example, in the MMPI, there were
several items which reflected older word usage (such
as playing ‘‘drop the handkerchief’’). While the re-
vised MMPI (MMPI-2) has eliminated anachronistic
items, in 1991 Butcher and his colleagues found that
nearly all of the age differences in the MMPI-2 still
reflected either differing health statuses or cohort dif-
ferences in language and experience (e.g., the use of
marijuana was much less likely to be endorsed by
older groups).
Many instruments commonly in use in psychology
were developed on student populations, and, as such,
may have poor ecological validity for the elderly. For
example, a mastery or control instrument may include
items about perceived fairness of grading practices or
juggling work versus parenting roles. Certainly, any
instruments used to assess mental health in the elderly
must be sensitive to items that are more relevant to
student or young adult experiences.
Less obvious sources of poor ecological validity
may lie in cohort differences in reporting style. The
current cohort of elders may be less willing to reveal
emotional distress and/or use different terminology to
refer these states. Older men in particular may be less
comfortable in identifying stressors thanyoungermen.
The possibility of response bias in the elderly has
some interesting implications for the relative validity
of diagnostic techniques. There is surprisingly little re-
search available comparing the validity of self-report
versus observer ratings in the elderly for specific ill-
nesses. In general, observer ratings are thought to be
more objective than self-report inventories, although
there may be age-related biases in observer ratings, re-
flecting stereotypical biases about elders as more im-
paired, irascible, and so on.
A further problem is that clinical interviews often
yield categoricalclassification,forexample,full-blown
depression versus none. To the extent that elders, even
in clinical interviews, under-report symptoms, then
such procedures may underestimate the existence of
problems. For example, in 1992 Koenig and Blazer re-
viewed studies showing that the prevalence of major
depression in the elderly, based upon clinical inter-
views, was about 1% (which is rather less than that
reported for younger populations), but some 20% or
more of older samples reported problems with nega-
tive affect on self-rated inventories, a figuremuchmore
comparable to younger samples. This is not to say that
different criteria or cutoff points on standardized clini-
cal assessment tools necessarily need to be developed,
but rather that much more research is needed into this
issue.
II. DIFFERENTIATING BETWEEN MENTAL
AND PHYSICAL HEALTH PROBLEMS
Perhaps the issue which has received the most atten-
tion in the literature concerns the differentiation be-
tween mental and physical health. Many mentalhealth
scales include physical symptoms, which may be rela-
tively uncommon in younger populations and indica-
tive of psychological distress. However, in older pop-
ulations, with their greater incidence of chronic health
problems, such instruments may yield very high rates
of false positives. Further, mental health problems
often have physiological concomitants, and physical
health problems can affect psychological states. Ob-
viously, identifying the primary source of the symp-
toms is crucial in determining treatment options, al-
though sometimes the only way in which to determine
the precise etiology for a particular illness is to test
different treatments. However, there are critical issues
in differentiating anxiety, depression, and psychoses
from a variety of physical health problems.
A. Differentiating Depression and Anxiety
from Physical Health Problems
Self-report inventories of depression typically include
many somatic complaints, such as fatigue, headaches,
back and neck pain, constipation, and sleep distur-
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ergy, and psychomotor slowing, even in the absence
of depression. A number of different screening inven-
tories have been developed to differentiate between
these types of disorders.
In 1992, Newman and Sweet identified a number
of different features which may distinguish depression
from dementia. Depression often has a rapid onset
while dementia often has a gradual one. In addition,
there may be differences in both patient and familial
awareness of the problems, with recognition greater in
depression-related cognitive impairment than in prob-
lems related to dementia. Patients who are depressed
may be able to provide greater detail about their im-
pairment and to manifest subjective distress, while de-
menting patients may have vague, nonspecific com-
plaints and may be more likely to conceal cognitive
deficits. Depressed patients typically show poor moti-
vation and give up easily on tasks, while dementing
patients may struggle with tasks.
In addition, there are a number of differences be-
tween the two groups in both cognitive testing and
neurological examination. For example, depressedpa-
tients typically have problems with both recent and
long-term memory, and report poorer concentration
than actual knowledge testing, whereas dementia pa-
tients typically have much worse recent than long-
term memory deficits and general knowledge is worse
than concentration skills. Finally, depressive patients
typically demonstrate no problems with specific neu-
rological testing, while dementing patients typically
present with dyspraxias and agnosias, and show ab-
normal CAT scans, with increased ventricular size. In
addition, the administration of antidepressive medi-
cations may be one way to distinguish depression-
related pseudodementias from true dementias result-
ing from neurological disorders.
C. Distinguishing Schizophrenia
from Dementia
While the onset of schizophrenia typically occurs in
adolescence or young adulthood, schizophrenia may
also occur in late life. Schizophrenia with a late life
onset is often called paraphrenia, and may occur in
individuals who have a history of eccentricity and are
socially isolated. However, dementia can also produce
hallucinations and delusions, and thus, like depres-
sion, it is important to distinguish between the two
conditions.
bances. While in younger individuals these types of
complaints may be indicative of depression, such
symptoms are very common among the elderly. Thus,
this inclusion of physical health symptoms in psycho-
logical assessment instruments may lead to Type I er-
rors. On the other hand, there is some indication that
depression in the elderly may be presented in terms of
physical symptoms, and a relatively high proportion
of medical visits to general practitioners by the elderly
may be due to depression manifesting in physical com-
plaints. Thus, screening for recent life events and/or
changes in living conditions (see below) may be an
important way for clinicians to determine whether be-
reavement or social isolation may be important fac-
tors underlying such visits.
On the other hand, many illnesses common to the
elderly, as well as prescribed medications, may have
concomitant symptoms of depression and anxiety. For
example, elders are at increased risk for hypothyroid-
ism, cardiovascular disease, and chronic obstructive
pulmonary disorder, which may cause fatigue, sleep
disturbances, and negative affect. Other disorders,
such as myocardial infarctions, vitamin deficiencies,
anemia, pneumonia, and hyper- and hypothyroidism,
may present with symptoms of anxiety. Further, many
medications commonly prescribed in the elderly, such
as antihypertensives, may also create symptoms of de-
pression. Thus, physical, mental, and social health
are often tightly intertwined in the elderly, and multi-
pronged assessment techniques may be necessary to
adequately establish the etiology of symptoms of de-
pression and anxiety in the elderly.
B. Differentiating Depression
from Dementia
Some depressive symptoms mimic cognitive impair-
ment, especially in the elderly. In particular, psycho-
motor retardation and memory lapses in the elderly
are usually attributed to dementing processes, but ac-
tually may reflect depression. Pseudodementias can
result from a wide variety of disorders, including nu-
tritional deficiencies, prescribed medications, alcohol
and substance abuse, and surgical procedures. Thus,
assessment of the occurrence of problems of this type
may be an important component in elders presenting
with cognitive impairment. In turn, dementia is often
associated with difficulty concentrating, loss of en-
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Given that late-life onset of schizophrenia is rela-
tively rare, very few systematic studies have been
conducted. However, neuropsychological assessment
studies have been done, and, in many cases, it is pos-
sible to rule out dementing processes.
D. Assessment of Behavioral Disorders
Particularly disturbing concomitants of the cognitive
and affective disorders prevalent in late life are be-
havioral disturbances. These disturbances, including
wandering, sleep disruptions, verbal and physical ag-
gression, and hallucinations and delusions, may have
serious impacts on the quality of life for both elderly
individuals and their caretakers. Patients who exhibit
such behaviors may be labeled as ‘‘problems’’ by nurs-
ing home staff and then regularly given psychotropic
medication to control their behavior, which can result
in a variety of adverse physical, cognitive, and affec-
tive side effects. While there have been regulatory ef-
forts to decrease the use of psychotropic medications
in nursing homes, paradoxically, this regulation can
result in increased use, as nurses are given less discre-
tion and physicians must prescribe the use of such
drugs on a regular basis.
In 1994, Teri and Logsdon reviewed the variety of
scales which have been developed fairly recently to as-
sess behavioral disturbances. These typically are ob-
servational measures, and may be administered by re-
searchers, clinicians, nurses, or caregivers. A major
purpose of these scales is to quantify the frequency
and severity of such disturbances to devise appropri-
ate treatment strategies. Detailing the exact pattern of
aggressive and disruptive behavior may result in a
more objective picture of the actual problems created
by such patients, facilitate behavioral intervention,
and result in less relianceonpsychotropicmedications.
III. ASSESSING FACTORS AFFECTING
MENTAL AND PHYSICAL HEALTH
There are a variety of factors which can affect physical
and mental health in late life. In terms of behavioral
factors, alcohol and substance abuse, as well as stress,
are two of the most important ones.
A. Assessing Alcohol and
Substance Abuse in the Elderly
In the late 1960s Cahalan and his associates devel-
oped a survey assessment instrument for alcohol con-
sumption and problems. It assessed alcohol consump-
tion using three different scales: (1) the usual number
of drinks of beer, wine, and distilled spirits consumed
‘‘nowadays,’’ as reported in drinks per day, week,
month, or year; (2) the number of drinks of beer, wine
and distilled spirits consumed the day before complet-
ing the questionnaire; and (3) the regularity of alcohol
consumption on specific days of the week. For ex-
ample, a respondent may indicate that, in a typical
week, he or she drinks one glass of wine during the
evenings and two drinks each on Friday and Saturday
night. Thus, this individual, on average, drinks nine
drinks a week, which then usually is translated into
drinks per year.
Independently of consumption, respondents indi-
cate the frequency (e.g., never, once per week, month,
or year) of experiencing alcohol problems. Theseitems
assess the frequency with which alcohol affects physi-
cal, psychological, or social functioning. In general,
convictions for drunk driving and alcohol-relatedtraf-
fic accidents are weighted more heavily than other
types of problems. Although they reflect some com-
ponents of a DSM-IV diagnosis of alcoholism, they do
not permit such a diagnosis, which requires the use of
a diagnostic interview.
The shortest and simplest self report of alcohol
abuse is the four-item CAGE instrument, in which a
positive response to two or more of the items suggests
alcohol abuse. The items assess feeling that one should
drink less, being annoyed by others’ criticizing one’s
drinking, feeling guilty about drinking, and drinking
in the morning. The items have good face validity, yet
this instrument does not appear to be sensitive in older
populations. The Michigan Alcoholism Screening Test
(MAST) for older adults is a much longer (24-item)
instrument that has been validated on the hospitalized
elderly but may not be practical for screening outside
hospitalized populations. It should be noted that other
versions of the MAST have not been equally valid in
all populations tested.
The use of self-report surveys of alcohol consump-
tion and problems may prove difficult, especially with
the elderly. However, for the general population, Mi-
danik concluded in 1988 that ‘‘the validity of self-
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is distinct from that associated with senile dementias
such as Alzheimer’s and even Korsakoff’s Syndrome
(which involves irreversible brain damage due to long-
term severe alcohol abuse). This pattern is summa-
rized in DSM-IV as involving deficits in memory, lan-
guage, motor functions, object recognition (without
organic motor or sensory impairment), and abstract
thinking and planning. Evidence has supported this
diagnostic approach with an additional strong finding
that name-finding was almost completely spared in
alcohol-related dementias, in contrast to Alzheimer’s
Disease, in which dysnomia is pronounced.
Second, and perhaps most helpful, are in-home as-
sessments. In addition to standard consumption inter-
views and listing the prescriptions and home remedies
that the elderly use, other data and relatively unobtru-
sive observations can be employed. These include a
history of falls, grooming, odors present in the house
(also, obviously, useful for an assessment of tobacco
use), bruises at the level of furniture, tremors, incon-
tinence, and many others (many of which could be
associated with non-alcohol-related dementias or de-
pression). Naturally, such an assessment would re-
quire considerable training and would obviously be
available only for that minority of the elderly who
receive home care from outside agencies.
Unfortunately, there is no good way of assessing
the dependence on prescription tranquilizers (prin-
cipally benzodiazepines) in the elderly unless with-
drawal symptoms, such as extreme anxiety and ir-
ritability, occur since dependence is not typically
associated with dose increase. Such dependence is
more frequent among elderly women than men. Signs
of toxicity from long-term use are easily mistaken for
other disorders of the elderly, such as memory loss and
other cognitive impairments, as well as problems with
mobility. It is likely that alcohol and drug abuse may
reflect the levels of stress in elders’ lives.
B. Assessing Stress
and Coping in Late Life
There are several different ways of assessing stress,
including traumatic events, life events, chronic role
strain, and daily stressors or hassles. In the last de-
cade, it has rapidly become apparent that both type
and frequency of stressors change with age. While
early studies suggested that the number of stressful life
reports is not an either/or phenomenon.’’ There is
no ‘‘gold’’ standard against which to compare self-
reports, only a variety of ‘‘lead’’ standards such as
collateral reports, diaries, official records, laboratory
tests, or interviews. All of these methods assess over-
lapping but nonisomorphic aspects of an individual’s
alcohol use. Sobell and Sobell noted in 1990 that
the relevant issue is the extent of discrepancy among
sources of information that are being used to investi-
gate a given research question. The latter observation
may be especially relevant for the elderly.
Tobacco, alcohol, and prescription drugs (usually
anxiolytics) are the most abused drugs in the elderly.
Indeed, alcohol consumption both reduces thiamine
uptake and interacts with prescription drug use, a fact
that is further complicated by the reduced capacity of
elderly persons for clearing such drugs. Thus, use of
both types of substances may carry a risk for health
problems that increases with age. Moreover, the el-
derly may not recognize that their relatively nonprob-
lematic levels of consumption at younger ages may
cause problems in later life.
While drinking has been shown to decline with age,
this may not be a reliable predictor of future trends
since recent research has shown that changes in drink-
ing patterns appear to be more closely associated with
period rather than age effects. These considerations
may render assessment of risk for problem drinking
(with its attendant drug interactions) more difficult in
the elderly.
In 1997, Atkinson argued that the relatively low re-
ported rates of alcoholism in those over the age of
60 (no more than 2% in men and less than 1% in
women) may underestimate the actual prevalence of
problems) largely due to a failure to accurately report
consumption and problems in surveys. The ‘‘discrep-
ancy problem’’ may be more pertinent among the el-
derly than in younger populations. Thus, there may be
special difficulties with self-report in the elderly, with
a problem/reported problem ratio perhaps increasing
with age. This is further complicated by cohort effects,
with younger cohorts more willing to acknowledge
problems than older ones, if such cohort differences
are maintained in later life.
Excluding daily blood alcohol level testing, there
are several reasonable supplements to self-report in
the elderly. First, there is a pattern of cognitive deterio-
ration associated with alcohol abuse in the elderly that
6
Assessment of Mental Health in Older Adults
