Table Of Content41
Psychiatry
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about the book… e
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Formatted as a stand-alone text, Mood Disorders in Later Life examines the varied spectrum of mood
o o
disorders encountered in older adults, including minor depressive disorders, unipolar and bipolar disorders,
n
bereavement, vascular depression, depression with comorbid medical disorders, and depression with psychotic d o
features. Highlighting diagnostic assessment and state of the art treatment interventions that can improve
clinical outcomes, this hands-on resource explores the range of current therapeutic interventions for mood E d
disorders in later life. d
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This Second Edition is revised to include current information on bipolar disorders and expanded material on: td
• current diagnostic assessment of minor and major depressive disorders io ood
• cross-cultural issues that can affect treatment outcome n i
• overcoming the barriers to treatment adherence s
• addressing the significance of comorbid medical conditions
o d
• evidence-based psychotherapeutic and somatic approaches to treatment
• risk assessment and suicide prevention r isorders
• the effectiveness of maintenance treatment
d
With thorough discussion of diagnostic approaches and detailed suggestions for psychotherapeutic and
somatic treatment interventions, Mood Disorders in Later Life is a key, single-source reference for health care e
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professionals who treat older adults. r
in ater ife
about the editors... s
JAMES M. ELLISON is Clinical Director of the Geriatric Psychiatry Program and Director of the Memory Disorders
Clinic at McLean Hospital, Belmont, and Associate Professor of Psychiatry, Harvard Medical School, Boston, i
n
Massachusetts, USA. He received his M.D. from University of California Medical School in San Francisco,
California and his M.P.H. from the Harvard School of Public Health, Boston, Massachusetts, USA. Dr. Ellison’s
clinical work and research interests focus on mood and cognitive disorders of later life. He is a Distinguished L
Fellow of the American Psychiatric Association, a Curriculum Committee member of the American Society of Second Edition
Clinical Psychopharmacology, and a member of the American Association for Geriatric Psychiatry. He is a a
reviewer for several journals and has edited and contributed to books on psychopharmacology, anxiety
t
disorders, neuropsychiatry, and the care of suicidal patients in managed care settings. Dr. Ellison is also the
co-editor of Informa Healthcare’s 2003 title, Depression in Later Life: A Multidisciplinary Psychiatric Approach. e
HELEN H. KYOMEN is Assistant Psychiatrist, McLean Hospital, Belmont, Massachusetts, Clinical Instructor in r
Medical Psychiatry Series / 41
Psychiatry, Harvard Medical School, Boston, Massachusetts, USA, and Medical Director, MetroWest Medical
Center Geropsychiatric Treatment Unit, Natick and Framingham, Massachusetts, USA. Dr. Kyomen received L
her MD from the University of Southern California, Los Angeles, California, USA and her MS in Epidemiology
from the Harvard School of Public Health, Boston, Massachusetts, USA. She is a graduate of the Harvard School i
of Public Health Program in Clinical Effectiveness and the Harvard Medical School Division on Aging/National f
Institute on Aging Mentored Clinical Scientist Development Program and serves as Principal Investigator of the e
ongoing study, “Bio-Psycho-Social-Cultural Aspects of Mood and Behavioral Disturbances in Geropsychiatric P
A
Patients: Cross-Sectional and Longitudinal Perspectives.” She has been a recipient of several prestigious awards, N
including the Merck U.S. Human Health/American Geriatrics Society New Investigator Award and the American T
Geriatrics Society Presidential Poster Award. She is an ad hoc reviewer for the American Journal of Psychiatry, the O
N
American Journal of Geriatric Psychiatry, and the Journal of the American Geriatrics Society.
E
SUMER VERMA is Director of the Geriatric Psychiatry Fellowship and Educational Programs, McLean Hospital, Ellison 2
Belmont, Associate Professor of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA, Edited by 8
• 7
and Lecturer on Psychiatry at Harvard Medical School, Boston, Massachusetts, USA. He is the Medical Director C
of the Alzheimers Unit at Briarwood Nursing Facility in Needham Massachusetts, USA. Dr. Verma received his Kyomen V
M.B;B.S from Medical College Amritsar, India and M.D.(Gastroenterology) from Punjab University, Chandigarh, James M. Ellison
•
India. He has a number of national teaching awards and most recently was recognized by Psychiatric Times as P
“Teacher of the Year” in 2000. Dr. Verma is also the co-editor of Depression in Later Life: A Multidisciplinary Verma A
N
Psychiatric Approach. Helen H. Kyomen T
H5329 O
Printed in the United States of America N
Sumer Verma E
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in ater ife
http://avaxhome.ws/blogs/ChrisRedfield
MEDICAL PSYCHIATRY
SeriesEditorEmeritus
WilliamA.Frosch,M.D.
WeillMedicalCollegeofCornellUniversity,
NewYork,NewYork,U.S.A.
AdvisoryBoard
JonathanE.Alpert,M.D.,Ph.D. SiegfriedKasper,M.D.
MassachusettsGeneralHospitaland MedicalUniversityofVienna
HarvardUniversitySchoolofMedicine Vienna,Austria
Boston,Massachusetts,U.S.A.
MarkH.Rapaport,M.D.
BennettLeventhal,M.D. Cedars-SinaiMedicalCenter
UniversityofChicagoSchoolofMedicine LosAngeles,California,U.S.A.
Chicago,Illinois,U.S.A.
1. HandbookofDepressionandAnxiety:ABiologicalApproach,editedbyJohanA.
denBoerandJ.M.AdSitsen
2. AnticonvulsantsinMoodDisorders,editedbyRussellT.JoffeandJosephR.
Calabrese
3. SerotonininAntipsychoticTreatment:MechanismsandClinicalPractice,editedby
JohnM.Kane,H.-J.Moller,andFransAwouters
4. HandbookofFunctionalGastrointestinalDisorders,editedbyKevinW.Olden
5. ClinicalManagementofAnxiety,editedbyJohanA.denBoer
6. Obsessive-CompulsiveDisorders:Diagnosis•Etiology•Treatment,editedbyEric
HollanderandDanJ.Stein
7. BipolarDisorder:BiologicalModelsandTheirClinicalApplication,editedby
L.TrevorYoungandRussellT.Joffe
8. DualDiagnosisandTreatment:SubstanceAbuseandComorbidMedicaland
PsychiatricDisorders,editedbyHenryR.KranzlerandBruceJ.Rounsaville
9. GeriatricPsychopharmacology,editedbyJ.CraigNelson
10. PanicDisorderandItsTreatment,editedbyJerroldF.RosenbaumandMarkH.
Pollack
11. ComorbidityinAffectiveDisorders,editedbyMauricioTohen
12. PracticalManagementoftheSideEffectsofPsychotropicDrugs,editedby
RichardBalon
13. PsychiatricTreatmentoftheMedicallyIII,editedbyRobertG.Robinsonand
WilliamR.Yates
14. MedicalManagementoftheViolentPatient:ClinicalAssessmentandTherapy,
editedbyKennethTardiff
15. BipolarDisorders:BasicMechanismsandTherapeuticImplications,editedbyJair
C.SoaresandSamuelGershon
16. Schizophrenia:ANewGuideforClinicians,editedbyJohnG.Csernansky
17. PolypharmacyinPsychiatry,editedbyS.NassirGhaemi
18. PharmacotherapyforChildandAdolescentPsychiatricDisorders:SecondEdition,
RevisedandExpanded,DavidR.Rosenberg,PabloA.Davanzo,andSamuel
Gershon
19. BrainImagingInAffectiveDisorders,editedbyJairC.Soares
20. HandbookofMedicalPsychiatry,editedbyJairC.SoaresandSamuelGershon
21. HandbookofDepressionandAnxiety:ABiologicalApproach,SecondEdition,
editedbySiegfriedKasper,JohanA.denBoer,andJ.M.AdSitsen
22. Aggression:PsychiatricAssessmentandTreatment,editedbyEmilCoccaro
23. DepressioninLaterLife:AMultidisciplinaryPsychiatricApproach,editedby
JamesEllisonandSumerVerma
24. AutismSpectrumDisorders,editedbyEricHollander
25. HandbookofChronicDepression:DiagnosisandTherapeuticManagement,
editedbyJonathanE.AlpertandMaurizioFava
26. ClinicalHandbookofEatingDisorders:AnIntegratedApproach,editedbyTimothy
D.Brewerton
27. DualDiagnosisandPsychiatricTreatment:SubstanceAbuseandComorbid
Disorders:SecondEdition,editedbyHenryR.KranzlerandJoyceA.Tinsley
28. AtypicalAntipsychotics:FromBenchtoBedside,editedbyJohnG.Csernansky
andJohnLauriello
29. SocialAnxietyDisorder,editedbyBorwinBandelowandDanJ.Stein
30. HandbookofSexualDysfunction,editedbyRichardBalonandR.TaylorSegraves
31. BorderlinePersonalityDisorder,editedbyMaryC.Zanarini
32. HandbookofBipolarDisorder:DiagnosisandTherapeuticApproaches,editedby
SiegfriedKasperandRobertM.A.Hirschfeld
33. ObesityandMentalDisorders,editedbySusanL.McElroy,DavidB.Allison,and
GeorgeA.Bray
34. Depression:TreatmentStrategiesandManagement,editedbyThomasL.
SchwartzandTimothyJ.Petersen
35. BipolarDisorders:BasicMechanismsandTherapeuticImplications,Second
Edition,editedbyJairC.SoaresandAllanH.Young
36. NeurogeneticsofPsychiatricDisorders,editedbyAkiraSawaandMelvinG.
Mclnnis
37. AttentionDeficitHyperactivityDisorder:Concepts,Controversies,NewDirections,
editedbyKeithMcBurnett,LindaPfiffner,RussellSchachar,GlenRaymondElliot,
andJoelNigg
38. InsulinResistanceSyndromeandNeuropsychiatricDisorders,editedbyNatalieL.
Rasgon
39. AntiepilepticDrugstoTreatPsychiatricDisorders,editedbySusanL.McElroy,
PaulE.Keck,Jr.,andRobertM.Post
40. Asperger’sDisorder,editedbyJeffreyL.Rausch,MarieE.Johnson,andManuel
F.Casanova
41. MoodDisordersinLaterLife,SecondEdition,editedbyJamesM.Ellison,Helen
H.Kyomen,andSumerK.Verma
M
ood
d
isorders
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in ater ife
Second Edition
Edited by
James M. Ellison
McLean Hospital
Belmont, Massachusetts, USA
Helen H. Kyomen
McLean Hospital
Belmont, Massachusetts, USA
Sumer Verma
McLean Hospital
Belmont, Massachusetts, USA
InformaHealthcareUSA,Inc.
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[DNLM:1. MoodDisorders–diagnosis. 2. MoodDisorders–therapy.
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Preface
The high prevalence, frequent recurrence, and serious consequences of mood dis-
orders among young and middle-aged adults are well recognized. The effects
of mood disorders on older adults, however, have been less widely appreciated.
Although demographic studies indicate a low-point prevalence of major depres-
sive disorder and even lower prevalence of bipolar disorder among community-
dwellingelderlycohorts,theclinicalsignificanceofmoodsymptomsishighamong
the elderly, especially in medical and institutional settings. Mood disorders rep-
resent a major disease burden in later life, contributing to suffering, functional
impairment,medicaldisability,andexcessmortality.Notonlysuicideriskbutalso
morbidity and mortality appear to be increased in the presence of late-life mood
disorders.
GiventheagingoftheAmericanpopulationandtheenhancedsurvivalofmed-
icallycompromisedelders,itisincreasinglyimportantthatcliniciansknowhowto
evaluateandtreatlate-lifemooddisorders.Atpresent,however,evenrecognition
oftheseconditionsistoolimited.Seniorsmayminimizetheirpsychologicdistress
andfocusmoredirectlyonsomaticorcognitiveconcerns,inadvertentlyobscuring
thecorrectpsychiatricdiagnosis.Primarycareclinicians—thehealthcareproviders
likelytoseethegreatestnumberofaffectedelderlyindividualsandthereforemost
inneedofevaluationandmanagementskillscognizance—frequentlymissthecor-
rect diagnosis. Even when the proper diagnosis is made, elderly patients who
present mood symptoms to a primary care physician are less likely than younger
onestoreceiveappropriatetreatmentandadequatefollow-upcare. Mentalhealth
specialists, too, have shown a limited degree of recognition of mood disorders
amongolderpatients. Theneedisapparent,therefore,forgreaterclinicianaware-
nessofthespectrumofunipolarandbipolardisordersintheelderly,frommilder
to more severe syndromes, as well as for education of the public, with particular
focus on the family members and caregivers of older adults suffering from mood
disturbances.
The literature on treatment of late-life depression has grown to include many
treatment studies, while the literature on late-life bipolar disorder is still sparse.
Forbothtypesofdisorder,ourtherapeuticapproachesstillcontainmanyareasof
uncertainty.Treatmentsformooddisordersamongtheoldestold,themedicallyill,
orthedemented,forexample,havereceivedmuchlessattentionthantreatmentof
younger,medicallyhealthierolderadults.Beyondeffectsonsymptomalleviation,
we still know too little about how treatment affects quality of life. Furthermore,
we need to understand more about how to integrate somatic therapies with psy-
chotherapeutic approaches, now recommended by experts as an important treat-
mentmodalityforlate-lifedepressionandbipolardisorder.
iii
iv Preface
Withinvaluablecontributionsfromnotedexperts,wehavetriedinthisvolume
to present a comprehensive and current picture of late-life mood disorders. This
collection of essays is intended for use by all clinicians who evaluate and treat
elderly individuals with clinically significant mood symptoms. Psychiatrists and
othermentalhealthspecialistsaswellasprimarycarecliniciansshouldfindinits
pagesinformationthatisbothup-to-dateandpractical.Inaddition,wealongwith
theothercontributingauthorshaveattemptedtopresenttheseimportantillnesses
andtheirtreatmentsinalargercontext,highlightingcurrentlyavailableandevolv-
ingapproachestotreatmentandidentifyingareasinneedoffurtherinvestigation.
Itisourearnesthope,throughthepublicationofthisbook,toincreaseprofessional
andpublicawarenessoflate-lifemooddisorders,todisseminatethemostcurrent
knowledge, to help identify areas for further inquiry, and ultimately to add our
worktothatofothersdedicatedtoimprovingqualityoflifeinthelateryears.
JamesM.Ellison,MD,MPH
HelenH.Kyomen,MD
SumerK.Verma,MD
Acknowledgements
Editedbooks,attheirbest,incorporateexpertcontributionsonagiventopicintoa
broader view than any individual could achieve alone. Sometimes this breadth is
achievedattheexpenseofambiguitiesandstylisticinconsistenciesintroducedbya
writingprocessthatreliesuponindividualauthorswhoseparatelyshapeandsup-
ply theirportions ofthe final product. In thecase of this book, however, we were
fortunatetobeworkingwithagroupofcollaboratorswhoinmanycasesnotonly
contributedtheirownchaptersbutalsogenerouslyadvisedustowardtheoverall
goals of the book. The resulting volume, we hope, has enhanced the quality and
value of each author’s work. For their own chapters and their help in improving
theentirebook,theeditorswishtoexpresstheirgratitudetoeachofourcontribut-
ingauthors.Workingwiththemhasbeenarewardingexperience.Inaddition,two
researchassistantslenttheireditorialandwritingskills,offeringfarmoretimeand
energy to this book than we ever expected. We predict a bright future for these
youngcolleagues,LaurenZeranskiandBrittanyJordan.
The patients and staff of the McLean Hospital Geriatric Psychiatry Program,
wheretheeditorsareprivilegedtowork,alsodeserveourgratefulrecognition.They
havehelpedustounderstandboththedevastatingconsequencesofmooddisorders
andtheremarkablebenefitspossiblewhentreatmentiseffective.Ourrichclinical
experiencesatMcLeanHospitalhave,wehope,groundedthisbookclinicallysoas
toincreaseitspracticalvaluetopractitionerstreatingolderadults.
Finally, we wish to thank our families. One never appreciates in advance the
commitmentoftimethatwillberequiredtocompleteaprojectsuchasthis,butit
isalwaysbeyondanyinitialestimate.Ourspousesandchildrenhavemadeasilent
butabsolutelynecessarycontributiontoourworkbysharingourconvictionofits
importance and by encouraging our continued writing even at times when they
wouldhavepreferredourpresence.Fortheirloveandsupportinthepreparation
ofthisbook,asinsomanyotherareasofourlives,wewishtodedicateourworkto
them.
JamesM.Ellison,MD,MPH
HelenH.Kyomen,MD
SumerK.Verma,MD
v
