Mental Health: A Report of the Surgeon General
Thakker, J.. & Ward, T. (1998). Culture and classification:
The cross-cultural application of the DSM- IV. Clinical
  Psychology Review, 18, 501-529.
Thase, M. E. (1993). Maintenance treatments of recurrent
affective disorders. Current Opinions in Psychiatry, 6,
  16-21.
Thase, M. E. (1995). Reeducative psychotherapies. In G. 0.
Gabbard (Ed.), Treatment ofpsychiatric disorders (pp.
1169-1204). Washington, DC: American Psychiatric
  Press.
Thase, M. E. (1996). The undertreatment of patients with
  depression. Depressive Disorders: Index and Review,
  4, 1.
Thase, M. E. (1998). Depression, sleep, and antidepressants.
Journal of Clinical Psychiatry, .59(Suppl. 4), 55-65.
Thase, M. E., Blomgren, S. L., Birkett, M. A., Apter, J. T., &
Tepner, R. G. (1997a). Fluoxetine treatment of patients
with major depressive disorder who failed initial
treatment with sertraline. JournalofClinical Psychiatry,
  58, 16-21.
Thase, M. E., Greenhouse, J. B., Frank, E., Reynolds, C. F.,
III, Pilkonis, P. A., Hurley, K., Grochocinski, V., &
Kupfer, D. J. (1997b). Treatment of major depression
with psychotherapy or psychotherapy-pharmacotherapy
combinations. Archives of General Psychiatry, 54,
  1009-1015.
Thase, M. E., & Howland, R. H. (1995). Biological
processes in depression: An updated review and
integration. In E. E. Beckham & W. R. Leber (Eds.),
Handbook of depression (2nd ed., pp. 213-279). New
  York: Guilford Press.
Thase, M. E., Mallinger, A. G., M&night, D., &
Himmelhoch, J. M. (1992). Treatment of imipramine-
resistant recurrent depression, IV: A double-blind
crossover study of tranylcypromine for anergic bipolar
depression, American Journal of Psychiatry, 149,
  195-198.
Thase, M. E., & Rush. A. J. (1995). Treatment resistant
depression. In F. E. Bloom & D. J. Kupfer (Eds.),
Psychopharmacology: The fourth generation of
progress (pp. 1081-1097). New York: Raven Press.
Thase, M. E.. & Rush, A. J. (1997). When at first you don't
  succeed:  Sequential strategies for antidepressant
nonresponders. Journal of Clinical Psychiatry,
  58(Suppl. 13), 23-29.
Thase, M. E.. Simons, A. D., Cahalane, J., McGreary, J., &
Harden, T. (1991). Severity of depression and response
to cognitive behavior therapy. American Journal of
  Psychiatry, 148,784-789.
Thase, M. E., & Sullivan, L. R. (1995). Relapse and
recurrence of depression: A practical approach for
prevention. CNS Drugs, 4, 26 l-277.
Thase, M. E., Trivedi, M. H., & Rush, A. J. (1995). MAOIs
in the contemporary treatment of depression.
Neuropsychopharmacology, 12, 185-219.
Thorn, G. R., Chosak, A., Baker, S. L., & Barlow, D. H.
(1999). Psychological theories of panic disorder. In D.
J. Nutt, J. C. Ballenger, & J. P. Lepine (Eds.), Panic
  disorder:  Clinical diagnosis, management and
mechanisms (pp. 93-108). London: Martin Dunitz Ltd.
Tignol, J. (1993). A double-blind, randomized, fluoxetine-
controlled, multicenter study of paroxetine in the
treatment of depression. Journal of Clinical
Psychopharmacology, 13, 18S-22s.
Toomey, R., Faraone, S. V., Simpson, J. C., & Tsuang, M. T.
(1998). Negative, positive, and disorganized symptom
dimensions in schizophrenia, major depression, and
bipolar disorder. Journal of Nervous and Mental
  Disease, 186,47H76.
Torrey, E. F., & Yolken, R. H. (1998). At issue: Is household
crowding a risk factor for schizophrenia and bipolar
  disorder? Schizophrenia Bulletin, 24, 321-324.
Trainor, J., Shepard, M., Boydell, K. M., & Magura, S.
(1997). Beyond the service paradigm: The impact and
  implications  of consumer/survivor initiatives.
  Psychiatric Rehabilitation Journal, 21, 132-140.
Trugman, J. M. (1998). Tardive dyskinesia: Diagnosis,
pathogenesis, and management. The Neurologist, 20,
  90-93.
Tsuang,, M., & Faraone, S. V. (1990). The genetics of mood
disorders. Baltimore: Johns Hopkins University Press.
Tsuang, M. T., & Faraone, S. V. (1995). The case for
heterogeneity in the etiology of schizophrenia.
Schizophrenia Research, 17, 161-175.
Tsuang, M. T., Gilbertson, M. W., & Faraone, S. V. (1991).
The genetics of schizophrenia. Current knowledge and
  future directions. Schizophrenia Research, 4, 157-l 7 1.
Turner, J. C., & TenHoor, W. J. (1978). The NIMH
  Community Support Program: Pilot approach to a
  needed social reform. Schizophrenia Bulletin, 4,
  319-348.
326

Adults and Mental Health
Turner, R. J., & Lloyd, D. A. (1995). Lifetime trauma and
mental health: The significance of cumulative adversity.
Journal of Health and Social Behavior, 36, 360-376.
Turner, R. J., Wheaton, B., & Lloyd, D. A. (1995). The
epidemiology of stress. American Sociological Review,
  60, 104-12.5.
Ulbrich, P. M., Warheit, G. J., & Zimmerman, R. S. (1989).
Race, socioeconomic status, and psychological distress:
An examination of differential vulnerability. Journal of
  Health and Social Behavior, 30, 13 l- 146.
Umbricht, D., & Kane, J. M. (1995). Risperidone: Efficacy
and safety. Schizophrenia Bulletin, 21,593-606.
US. Department of Education. (1998). Disability Forum
Report-3. Housing and disability: Data needs, statistics
and policy. Proceedings of the Third National Disability
  Statistics and Policy Forum. Washington, DC: National
  Institute on Disability and Rehabilitation Research.
U.S. Department of Health and Human Services. (1996).
Physical activity and health: A report of the Surgeon
  General. Atlanta, GA: U.S. Department of Health and
  Human Services, Centers for Disease Control and
  Prevention, National Center for Chronic Disease
  Prevention and Health Promotion.
U.S. Department of Housing and Urban Development.
  (1994). Worse case need for housing assistance in the
  U.S. in 1990 and 1991: A report to Congress.
Washington, DC: HUD Office of Policy Development
  and Research.
Vaillant, G. E. (1977). Adaptation to life. New York: Basic
  Books.
Van OS, J., & Marcelis, M. (1998). The ecogenetics of
schizophrenia: A review. Schizophrenia Research, 32,
  127-135.
Van OS, J., & Selten, J. P. (1998). Prenatal exposure to
maternal stress and subsequent schizophrenia. The May
  1940 invasion of The Netherlands. British Journal of
  Psychiatry, 172, 324-326.
Van OS, J., Wright, P., & Murray, R. M. (1997). Follow-up
studies of schizophrenia. I: Natural history and non-
psychopathological predictors of outcome. European
Psychiatry, 12, 327S-341s.
Van Putten, T., Marder, S. R., & Mintz, J. (1990). A
controlled dose comparison of haloperidol in newly
admitted schizophrenic patients. Archives of General
Psychiatry, 47, 754-758.
Van Putten, T., Marder, S. R., Mintz, J., & Poland, R. E.
(1992). Haloperidol plasma levels and clinical response:
A therapeutic window relationship. American Journal of
Psychiatry, 149,500-505.
Van Tosh, L., & de1 Vecchio, P. (in press). Consumer/
survivor-operated self-help programs: A technical
report. Washington, DC: U.S. Department of Health and
  Human Services.
Vanelle, J. M. (1997). Refractory schizophrenia: Historical
and currently prevailing criteria and definitions.
European Psychiatry, 12,32lS-326s.
Vaughan, S. C., & Oldham, J. M. (1997). Behavioral and
adaptive functioning. In A: Tasman, J. Kay, & J. A.
Lieberman (Eds.), Psychiatry, (Vol. 1, pp. 549-562).
  Philadelphia: W. B. Saunders.
Viguera, A. C., & Cohen, L. S. (1998). The course and
management of bipolar disorder during pregnancy.
Psychopharmacology Bulletin, 34, 339-346.
Vita, A., Dieci, M., Giobbio, G. M., Garbarini, M.,
Morganti, C., Braga, M., & Invemizzi, G. (1994). A
reconsideration of the relationship between cerebral
structural abnormalities and family history of
schizophrenia. Psychiatry Research, 53,41-55.
Vogel, H. S., Knight, E., Laudet, A. B., & Magura, S.
  (1998). Double trouble in recovery. Self-help for people
with dual diagnoses. Psychiatric Rehabilitation Journal,
  211356-364.
Wachtel, H. (1990). The second-messenger dysbalance
hypothesis of affective disorders. Pharmacopsychiatry,
  23,27-32.
Wahl, 0. F., Borostovik, L., & Rieppi, R. (1995).
Schizophrenia in popular periodicals. Communit?
  Mental Health Journal, 31, 239-248.
Wahl, 0. F., & Harman, C. R. (1989). Family views of
stigma. Schizophrenia Bulletin, 15, 131-139.
Walker, P. W., Cole, J. O., Gardner, E. A., Hughes, A. R.,
Johnston, J. A., Batey, S. R., & Lineberry, C. G. (1993).
  Improvement  in fluoxetine-associated sexual
dysfunction in patients switched to bupropion. Journal
of Clinical Psychiatry, 54,459-465.
Walters, V. L., Tognolini, R. Z., Rueda, H. M., Rueda. R.
M., & Torres, R. G. (1997). New strategies for old
problems: Tardive dyskinesia (TD). Review and report
on severe TD cases treated with clozapine. with 12, 8
and 5 years of video follow-up. Schizophrenia Research,
  28,23 l-246.
327

Mental Health: A Report of the Surgeon General
Ward. K. E., Friedman. L., Wise. A., & Schulz. S. C. (1996).
Meta-analysis of brain and cranial size in schizophrenia.
  Schizophrenia Research, 22, 197-213.
Ware, N. C., & Goldfinger, S. M. (1997). Poverty and
  rehabilitation in  severe psychiatric disorders.
Psychosocial Rehabilitation Journal, 21, 3-9.
Wehman, P. (1988). Supported employment: Toward equal
employment opportunity for persons with severe
  disabilities. Mental Retardation, 26. 357-361.
Wehr. T. A.. & Goodwin, F. K. (1987). Can antidepressants
  cause mania and worsen the course of affective illness?
American Journal of Psychiatry, 144, 1403-1411.
Weinberger, D. R. (1987). Implications of normal brain
development for the pathogenesis of schizophrenia.
  Archilves of General Psychiatry, 44, 66@-669.
Weinberger, D. R. (1995). Schizophrenia as a
  neurodevelopmental disorder. In S. R. Hirsch & D. R.
  Weinberger (Eds.), Schizophrenia (pp. 293-323).
Oxford. England, Cambridge. MA: Blackwell Science
  Ltd.
Weinberger. D. R., & Lipska, B. K. (1995). Cortical
  maldevelopment,  anti-psychotic drugs, and
schizophrenia:  A search for common ground.
  Schizophrenia Research, 16, 87-l 10.
Weiner, R. D.. & Krystal, A. D. (1994). The present use of
electroconvulsive therapy. Annual Review of Medicine,
  45, 273-28 1.
Weiss, J. M. (1991). Stress-induced depression: `Critical
neurochemical and electrophysiological changes. In J.
Madden (Ed.), Neurobiology of learning, emotion, and
affect (pp. 123-154). New York: Raven Press.
Weiss. E. L.. Longhurst, J. G.. & Mazure, C. M. (1999).
Childhood sexual abuse as a risk factor for depression in
women: Psychosocial and neurobiological correlates.
American Journal of Psychiat~, 156, 816-828.
Weissman, M. M., Bland, R. C.. Canino, G. J., Faravelli, C.,
Greenwald. S.. Hwu, H. G., Joyce, P. R., Karam, E. G.,
Lee. C. K.. Lellouch. J., Lepine, J. P., Newman, S. C.,
Oakley-Browne. M. A., Rubio-Stipec, M., Wells, J. E..
  Wickramaratne, P. J., Wittchen, H. U., & Yeh, E. K.
(1997). The cross-national epidemiology of panic
disorder. Archives of General Psychiatry, 54,305-309.
Weissman, M. M., Bland, R., Joyce, P. R., Newman, S.,
  Wells. J. E., & Wittchen, H. U. (1993). Sex differences
in rates of depression: Cross-national perspectives.
  Journal of Affective Disorders, 29, 77-84.
Wells, K. B., Katon, W., Rogers, B., & Camp, P. (1994). Use
of minor tranquilizers and antidepressant medications by
depressed outpatients: Results from the Medical
Outcomes Study. American Journal of Psychiatty, 151,
  694-700.
Wells, K. B., Rogers, W., Bumam, A., Greenfield, S., &
Ware, J. E., Jr. (1991). How the medical comorbidity of
depressed patients differs across health care settings:
Results from the Medical Outcomes Study. American
Journal of Psychiatv, 148, 1688-1696.
Wells, K. B., Stewart, A., Hays, R. D., Bumam, M. A.,
Rogers, W., Daniels, M., Berry, S., Greenfield, S., &
Ware, J. (1989). The functioning and well-being of
depressed patients. Results from the Medical Outcomes
Study. Journal of the American Medical Association,
  262,914-919.
Wells, K. B., Sturm, R., Sherboume, C. D., & Meredith, L.
S. (1996). Caring for depression. Cambridge, MA:
Harvard University Press.
Wender, P. H., Kety, S. S., Rosenthal, D., Schulsinger, F.,
Ortmann, J., & Lunde, I. (1986). Psychiatric disorders in
the biological and adoptive families of adopted
individuals with affective disorders. Archives of General
Psychiatry, 43,923-929.
Westenberg, H. G. (1996). Developments in the drug
treatment of panic disorder: What is the place of the
selective serotonin reuptake inhibitors? Journal of
Affective Disorders, 40, 85-93.
Wetzel, H., Szegedi, A., Hain, C., Wiesner, J., Schlegel, S.,
& Benkert, 0. (1995). Seroquel (ICI 204 636), a
putative "atypical" antipsychotic, in schizophrenia with
positive symptomatology: Results of an open clinical
trial and changes of neuroendocrinological and EEG
parameters. Psychopharmacology, 119,23 l-238.
Wible, C. G., Shenton, M. E., Hokama, H., Kikinis, R..
Jolesz, F. A., Metcalf, D., & McCarley, R. W. (1995).
Prefrontal cortex schizophrenia. A quantitative magnetic
resonance imaging study. Archives of General
Psychiatry, 52, 279-288.
Widiger, T. A., & Costa, P. T., Jr. (1994). Personality and
personality disorders. Journal ofAbnormal Psychology,
  103.78-9 1.
Wiersma. D., Nienhuis, F. J., Slooff, C. J., & Giel, R.
(1998). Natural course of schizophrenic disorders: A 15-
year followup of a Dutch incidence cohort.
Schizophrenia Bulletin, 24, 75-85.
328

Adults and Mental Health
Wilkinson, L. S., Killcross, S. S., Humby, T., Hall, F. S.,
Geyer. M. A., & Robbins, T. W. (1994). Social isolation
in the rat produces developmentally specific deficits in
prepulse inhibition of the acoustic startle response
without disrupting latent inhibition. Neurops~cho-
pharmacology, 10, 6 l-72.
Williams. J. W.. Jr., Rost, K., Dietrich, A.. Ciotti, M.,
Zyzanski, S., & Cornell, J. (1999). Primary care
physicians' approach to depressive disorders: Effects of
physician specialty and practice structure. Archives of
Family Medicine, 8, 58-67.
Wilt. S., & Olson, S. (1996). Prevalence of domestic
violence in the United States. Journal ofthe American
  Medical Women's Association, 51, 77-82.
Wing. J. (1962). Institutionalization in mental hospitals.
Journal of Social and Clinical Psychology, 1, 38-5 1.
Winokur. G., Coryell, W., Keller, M., Endicott, J., &
Akiskal, H. (1993). A prospective follow-up of patients
with bipolar and primary unipolar affectilie disorder.
Archives of General Psychiatry, 50,457-465.
Wiser, A. K.. Andreasen, N. C., O'Leary, D. S., Watkins, G.
  L., Boles Ponto, L. L., & Hichwa, R. D. (1998).
  Dysfunctional  cortico-cerebellar circuits   cause
"cognitive dysmetria" in schizophrenia. Neuroreport, 9,
  18951899.
Woods, B. T., & Yurgelun-Todd, D. (1991). Brain volume
loss in schizophrenia: When does it occur and is it
progressive? Schizophrenia Research, 5. 202-204.
World Health Organization. (1997). Psychosocial
  rehabilitation: A consensus statement. International
Journal of Mental Health, 26, 77-85.
Wyatt. R. J., Damiani. L. M., & Henter, I. D. (1998). First-
  episode  schizophrenia. Early intervention and
  medication discontinuation in the context of course and
treatment. British Journal of Psychiatry. Supplement,
  172, 77-83.
Wyatt. R. J., Green, M. F., & Tuma, A. H. ( 1997). Long-term
morbidity associated with delayed treatment of first
admission schizophrenic patients: A re-analysis of the
Camarillo State Hospital data. Psychological Medicine,
  27,261-268.
Wyatt, R. J., & Henter, I. D. (1998). The effects of early and
sustained intervention on the long-term morbidity of
schizophrenia. Journal of Psychiatric Research, 32.
  169-177.
Yehuda, R. (1999). Biological factors associated with
susceptibility to post-traumatic stress disorder. Canadian
Journal of Psychiatry, 44,34-39.
Yolken, R. H., & Torrey, E. F. (1995). Viruses,
schizophrenia,  and bipolar disorder. Clinical
Microbiology Reviews, 8, 131-145.
Yuen, O., Caligiuri, M. P., Williams. R., & Dickson, R. A.
(1996). Tardive dyskinesia and positive and negative
symptoms of schizophrenia. A study using instrumental
measures. British Journal of Psychiatry, 168,702-708.
Zaharia, M. D., Kulczycki, J., Shanks, N., Meaney, M. J.. &
Anisman, H. (1996). The effects of early postnatal
stimulation on Morris water-maze acquisition in adult
  mice: Genetic and maternal factors. Psychopharma-
  cology, 128,227-239.
Zalewski, C., Johnson-Selfridge, M. T., Ohriner, S., Zarrella,
  K.,  & Seltzer, J. C. (1998). A review of
neuropsychological differences between paranoid and
nonparanoid schizophrenia patients. Schizophrenia
  Bulletin, 24, 127-145.
Zealberg, J. J., Hardesty, S. J., Meisler, N., & Santos, A. B.
(1997). Mobile psychiatric emergency medical services.
In S. W. Henggeler & A. B. Santos (Eds.), Innovative
approaches for diflcult-to-treat populations (pp.
263-273). Washington, DC: American Psychiatric
  Press.
Zomberg, G. L., & Pope, H. G., Jr. (1993). Treatment of
depression in bipolar disorder: New directions for
research. Journal of Clinical Psychopharmacology, 13.
  397408.
Zubin, J., & Spring, B. (1977). Vulnerability-a new view of
schizophrenia. Journal of Abnormal Psychology, 86.
  103-126.
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CHAPTER 5
OLDER ADULTS AND MENTAL HEALTH
Contents
ChapterOverview .............................................................. 336
Normal Life-Cycle Tasks  .....................................................  337
Cognitive Capacity With Aging  ................................................  337
Change, Human Potential, and Creativity ......................................... 338
Coping With Loss and Bereavement  ............................................  339
Overview of Mental Disorders in Older Adults  .......................................  340
Assessment and Diagnosis  ....................................................  340
  Overview of Prevention  ......................................................  341
   Primary Prevention ....................................................... 342
   Prevention of Depression and Suicide  ........................................  342
    Treatment-Related Prevention  ... : ..........................................  342
   Prevention of Excess Disability  .............................................  343
   Prevention of Premature Institutionalization  ...................................  343
  OverviewofTreatment .......................................................  343
   Pharmacological Treatment  ................................................  344
     Increased Risk of Side Effects  ...........................................  344
     Polypharmacy  .......................................................  345
     Treatment Compliance .................................................  345
   Psychosocial Interventions .................................................  345
   Gap Between Efficacy and Effectiveness  .....................................  346
Depression in Older Adults .......................................................  346
Diagnosis of Major and "Minor" Depression ...................................... 346
   Late-Onset Depression .................................................... 347
    PrevalenceandIncidence ..................................................  347
   Barriers to Diagnosis and Treatment  .........................................  348
    Course .................................................................  349
    Interactions With Somatic Illness  ...........................................  350

Contents, continued
ConsequencesofDepression ................................................... 350
cost  ...................................................................... 351
Etiology of Late-Onset Depression  .............................................. 35 1
Treatment of Depression in Older Adults  ......................................... 352
Pharmacological Treatment  ................................................. 352
   Tricyclic Antidepressants ............................................... 352
  Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressants ........ 353
   MultimodalTherapy ................................................... 353
    CourseofTreatment ................................................... 354
  Electroconvulsive Therapy  ................................................. 354
Psychosocial Treatment of Depression ........................................ 355
Alzheimer'sDisease  ............................................................ 356
Assessment and Diagnosis of Alzheimer's Disease  ................................. 357
   Mild Cognitive Impairment  ................................................ 357
   Behavioral Symptoms  ..................................................... 359
    Course.. ............................................................... 359
    Prevalence andIncidence ................................................... 359
    Cost ................................................................... 360
Etiology of Alzheimer's Disease ................................................ 360
   Biological Factors  ........................................................ 360
  Protective Factors  ........................................................... 36 1
   Histopathology  .......................................................... 361
   Role of Acetylcholine  ..................................................... 36 1
Pharmacological Treatment of Alzheimer's Disease  ................................ 362
   Acetylcholinesterase Inhibitors  ............................................. 362
   Treatment of Behavioral Symptoms  .......................................... 362
Psychosocial Treatment of Alzheimer's Disease Patients and Caregivers  ................ 363
Other Mental Disorders in Older Adults  ............................................. 364
Anxiety Disorders  ........................................................... 364
   PrevalenceofAnxiety ..................................................... 364
   Treatment of Anxiety  ..................................................... 364

Contents, continued
Schizophrenia in Late Life  ....................................................  365
  Prevalence andCost ......................................................  365
Late-Onset Schizophrenia  .................................................  366
CourseandRecovery  .....................................................  366
Etiology of Late-Onset Schizophrenia  .................................. , ..... 366
Treatment of Schizophrenia in Late Life  ...................................... 367
Alcohol and Substance Use Disorders in Older Adults  .............................. 368
Epidemiology  .......................................................... 368
   Alcohol Abuse and Dependence  ......................................... 368
  Misuse of Prescription and Over-the-Counter Medications  .................... 368
   Illicit Drug Abuse and Dependence .......................................  369
  Course ................................................................. 369
Treatment of Substance Abuse and Dependence  ................................  370
ServiceDelivery  ............................................................... 370
  Overview of Services  ........................................................ 370
Service Settings and the New Landscape for Aging  .................................  371
   PrimaryCare ............................................................. 372
  Adult Day Centers and Other Community Care Settings .......................... 373
   NursingHomes ..........................................................  374
   Services for Persons With Severe and Persistent Mental Disorders  ................. 374
Financing Services for Older Adults  ............................................ 376
   Increased Role of Managed Care  ............................................ 376
   Carved-In Mental Health Services for Older Adults  .............................  376
   Carved-Out Mental Health Services for Older Adults  ............................  377
   Outcomes Under Managed Care  ............................................ 377
OtherServicesandSupports  ...................................................... 378
SupportandSelf-HelpGroups  ................................................. 378
Education and Health Promotion  ............................................... 379
FamiliesandCaregivers  ...................................................... 379
Communities and Social Services ............................................... 380
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._.........................  381

             CHAPTER 5
OLDER ADULTS AND MENTAL HEALTH
T he past century has witnessed a remarkable
lengthening of the average life span in the United
States, from 47 years in 1900 to more than 75 years in
the mid-1990s (National Center for Health Statistics
[NCHS], 1993). Equally noteworthy has been the
increase in the number of persons ages 85 and older
(Figure 5-l). These trends will continue well into the
next century and be magnified as the numbers of older
Americans increase with the aging of the post-World
War II baby boom generation.
Millions of older Americans-indeed, the major-
ity-cope constructively with the physical limitations,
cognitive changes,  and various losses, such as
bereavement, that frequently are associated with late
life. Research has contributed immensely to our
understanding of developmental processes that
continue to unfold as we age. Drawing on new
scientific information and acting on clinical common
sense, mental health and general health care providers
are increasingly able to suggest mental health strategies
and skills that older adults can hone to make this stage
of the life span satisfying and rewarding.
The capacity for sound mental health among older
adults notwithstanding, a substantial proportion of the
population 55 and older-almost 20 percent of this age
group-experience specific mental disorders that are
not part of "normal" aging (see Table 5-l). Research
that has helped differentiate mental disorders from
"normal" aging has been one of the more important
achievements of recent decades in the field of geriatric
health. Unrecognized or untreated, however.
depression, Alzheimer's disease, alcohol and drug
misuse and abuse, anxiety, late-life schizophrenia, and
other conditions can be severely impairing, even fatal;
Figure 5-1. Increases in the percent of the US. population over age 65 years and over age 65 years (Malmgren, 1994).
6.8%
1
.3%
1940
132 million
1960
180 million
     I 980
   227 million
Total U.S. Population
1990
249 million
2010
298 million
335

Mental Health: A Report of the Surgeon General
Table 5-1.  Best Estimate l-Year Prevalence Rates
      Based on Epidemiologic Catchment Area,
      Age 55+
Prevalence
("W
Any Anxiety Disorder         11.4 I
_. i _1 "_L. __. . .al.-.d. .;.a- Le.+* ._, .-.-   *_ i
  Simple Phobia                  7.3
                                    _.
Social Phobia             1.0
,,_ _,,. _ :-..  . . .  ^"I   __.,-.,- I. >dLL r.bd.-..i..r /._. I-& ,,..._..-.
  Agoraphobia                   4.1
                  `,               _.
:;;; P&ic'Disorder :`. - + a.",,     0.5
.(                    . .
  Obsessive-Compulsive Disorder       1.5
                 _(..". _.ji,.. ".,.. _
Any Mood Disorder                 4.4
.          ~.    t 1 ../
  Major Depressive Episode           3.8
-_ .x ^*         `" _             -",.
-.: __ _i k+ipolar Major Depression     ' -`-     3.7
                       . %"".e.   .I ._ . ."
  Dysthymia                     1.6
*'  Bipolar I                0.2
              
  Bipolar II                     0.1
. .y.`....~ fl   I,l(rl, _.    _I_._ .- , ."._ _ . .*.  . .- . . . .      .`
Schizophrenia           0.6
rurL.i: .      ".   `_..._ I . .   ( .., . . . . i ~. _.,
Somatization                     0.3
),. is-, ) .- x   , ;. . . .*:.         *< -. -_
Antibcial Personality Disorder    '     0.0
".*a." . ,. ,    . . . ^    . . . ..,..   ,_ . _ . ..., . * __ :
Anorexia Nervosa               010
".," I . .                                   I.
Seve're Cognitive Impairment           6.6
rX_"_leI" _           - . . .._ _    /-   ._c .,
Any Disorder
19.8
i
Source: D. Regier & W. Narrow, personal communication,
1999.
in the United States, the rate of suicide, which is
frequently a consequence of depression, is highest
among older adults relative to all other age groups
(Hoyert et al., 1999). The clinical challenges such
conditions present may be exacerbated, moreover, by
the manner in which they both affect and are affected
by general medical conditions or by changes in
cognitive capacities. Another complicating factor is
that many older people, disabled by or at risk for
mental disorders, find it difficult to afford and obtain
needed medical and related health care services. Late-
life mental disorders also can pose difficulties for the
burgeoning numbers of family members who assist in
caretaking tasks for their loved ones (Light &
Lebowitz, 1991).
Chapter Overview
Fortunately, the past 15 to 20 years have been marked
by rapid growth in the number of clinical, research, and
training centers dedicated to the mental illness- and
mental health-related needs of older people. As evident
in this chapter, much has been learned. The chapter
reviews, first, normal developmental milestones of
aging, highlighting the adaptivecapacities that enable
many older people to change, cope with loss, and
pursue productive and fulfilling activities. The chapter
then considers mental disorders in older people-their
diagnosis and treatment, and the various risk factors
that may complicate the course or outcome of
treatment. Risk factors include co-occurring, or
comorbid, general medical conditions, the high
numbers of medications many older individuals take,
and psychosocial stressors such as bereavement or
isolation. These are cause for concern, but, as the
chapter notes, they also point the way to possible new
preventive interventions. The goal of such prevention
strategies may be to limit disability or to postpone or
even eliminate the need to institutionalize an ill person
(Lebowitz & Pearson, in press). The chapter reviews
gains that have been realized in making appropriate
mental health services available to older people and the
challenges associated with the delivery of services to
this population. The advantages of a decisive shift
away from mental hospitals and nursing homes to
treatment in community-based settings today are in
jeopardy of being undermined by fragmentation and
insufficient availability of such services (Gatz &
Smyer, 1992; Cohen & Cairl, 1996). The chapter
examines obstacles and opportunities in the service
delivery sphere, in part through the lens of public and
private sector financing policies and managed care.
Finally, the chapter reviews the supports for older
persons  that extend beyond traditional, formal
treatment settings. Through support networks, self-help
groups, and other means, consumers, families, and
communities are assuming an increasingly important
336

role in treating and preventing mental health problems
and disorders among older persons.
Normal Life-Cycle Tasks
With improved diet, physical fitness, public health, and
health care, more adults are reaching age 65 in better
physical and mental -health than in the past. Trends
show that the prevalence of chronic disability among
older people is declining: from 1982 to 1994, the
prevalence  of chronic disability diminished
significantly, from 24.9 to 21.3 percent of the older
population (Manton et al., 1997). While some disability
is the result of more general losses of physiological
functions with aging (i.e., normal aging). extreme
disability in older persons, including that which stems
from mental disorders, is not an inevitable part of aging
(Cohen, 1988; Rowe & Kahn, 1997).
Normal aging is a gradual process that ushers in
some physical decline, such as decreased sensory
abilities (e.g., vision and hearing) and decreased
pulmonary and immune function (Miller, 1996;
Carman, 1997). With aging come certain changes in
mental functioning, but very few of these changes
match commonly held negative stereotypes about aging
(Cohen, 1988; Rowe & Kahn, 1997). In normal aging,
important aspects of mental health include stable
intellectual functioning, capacity for change, and
productive engagement with life.
Cognitive Capacity With Aging
Cognition subsumes intelligence, language, learning,
and memory. With advancing years, cognitive capacity
with aging undergoes some loss, yet important
functions are spared.  Moreover, there is much
variability between individuals, variability that is
dependent upon lifestyle and psychosocial factors
(Gottlieb, 1995). Most important. accumulating
evidence from human and animal research finds that
lifestyle modifies genetic risk in influencing the
outcomes of aging (Finch & Tanzi, 1997). This line of
research is beginning to dispel the pejorative
stereotypes of older people as rigidly shaped by
heredity and incapable of broadening their pursuits and
acquiring new skills.
Older Adults and Mental Health
A large body of research, including both cross-
sectional studies and longitudinal studies. has
investigated changes in cognitive function with aging.
Studies have found that working memory declines with
aging, as does long-term memory (Siegler et al., 1996),
with decrements more apparent in recall than in
recognition capacities. Slowing or some loss of other
cognitive functions takes place, most notably in
information processing, selective attention, and
problem-solving ability, yet findings are variable
(Siegler et al., 1996). These cognitive changes translate
into a slower pace of learnmg and greater need for
repetition of new information. Vocabulary increases
slightly until the mid-70s, after which it declines
(Carman, 1997). In older people whose IQ declines,
somatic illness is implicated in some cases (Cohen,
1988). Fluid intelligence, aformof intelligence defined
as the ability to solve novel problems, declines over
time, yet research finds that fluid intelligence can be
enhanced through training in cognitive skills and
problem-solving strategies (Baltes et al., 1989).
Memory complaints are exceedingly common in
older people, with 50 to 80 percent reporting subjective
memory complaints (cited in Levy-Cushman & Abeles,
in press). However, subjective memory complaints do
not correspond with actual performance. In fact, some
who complain about memory display performance
superior to those who do not complain (Collins &
Abeles, 1996). Memory complaints in older people,
according to several studies, are thought to be more a
product of depression than of decline in memory
performance (cited in Levy-Cushman & Abeles, in
press). (The importance of proper diagnosis and
treatment of depression is emphasized in subsequent
sections of this chapter.) Studies attempting to treat
memory  complaints  associated with normal
aging-using either pharmacological or psychosocial
means-have been, with few exceptions, unsuccessful
(Crook, 1993). In one of these exceptions, a recent
study demonstrated a significant reduction in memory
complaints with training workshops for healthy older
people. The workshops stressed not only memory
promotion strategies, but also ways of dealing with
337

Mental Health: A Report of the Surgeon General
expectations and perceptions about memory loss (Levy-
Cushman & Abeles, in press).
One large, ongoing longitudinal study found high
cognitive performance to be dependent on four factors,
ranked here in decreasing order of importance:
education, strenuous activity in the home, peak
pulmonary flow rate, and "self-efficacy," which is a
personality measure defined by the ability to organize
and execute actions required to deal with situations
likely to happen in the future (Albert et al., 1995).
Education, as assessed by years of schooling, is the
strongest predictor of high cognitive functioning. This
finding suggests that education not only has salutary
effects on brain function earlier in life, but also
foreshadows sustained productive behavior in later life,
such as reading and performing crossword puzzles
(Rowe & Kahn. 1997).
  The coexistence of mental and somatic disorders
(i.e., comorbidity) is common (Kramer et al., 1992).
Some disorders with primarily somatic symptoms can
cause cognitive. emotional, and behavioral symptoms
as well, some of which rise to the level of mental
disorders. At that point, the mental disorder may result
from an effect of the underlying disorder on the central
nervous system (e.g., dementia due to a medical
condition such as hypothyroidism) or an effect of
treatment (e.g.,  delirium due to a prescribed
medication). Likewise, mental problems or disorders
can lead to or exacerbate other physical conditions by
decreasing the ability of older adults to care for
themselves, by impairing their capacity to rally social
support, or by impairing physiological functions. For
example, stress increases the risk of coronary heart
disease and can suppress cellular immunity (McEwen,
1998). Depression can lead to increased mortality from
heart disease and possibly cancer (Frasure-Smith et al.,
1993, 1995; Penninx et al., 1998).
A new model postulates that successful aging is
contingent upon three elements: avoiding disease and
disability, sustaining high cognitive and physical
function, and engaging with life (Rowe & Kahn, 1997).
The latter encompasses the maintenance of
interpersonal relationships and productive activities, as
defined by paid or unpaid activities that generate goods
or services of economic value. The three major
elements are considered to act in concert, for none is
deemed sufficient by itself for successful aging. This
new model broadens the reach of health promotion in
aging to entail more than just disease prevention.
Change, Human Potential, and Creativity
Descriptive research reveals evidence of the capacity
for constructive change in later life (Cohen, 1988). The
capacity to change can occur even in the face of mental
illness, adversity, and chronic mental health problems.
Older persons display flexibility in behavior and
attitudes and the ability to grow intellectually and
emotionally. Time plays a key role. Externally imposed
demands upon one's time may diminish, and the
amount of time left at this stage in life can be
significant. In the United States in the late 20th century,
late-life expectancy approaches another 20 years at the
age of 65. In other words, average longevity from age
65 today approaches what had been the average
longevity from birth some 2,000 years ago. This leaves
plenty of time  to embark upon new social,
psychological, educational, and recreational pathways,
as long as the individual retains good health and
material resources.
In his classic developmental model, Erik Erikson
characterized the final stage of human development as
a tension between "ego integrity and despair" (Erikson,
1950). Erikson saw the period beginning at age 65
years as highly variable. Ideally, individuals at this
stage witness the flowering of seeds planted earlier in
the prior seven stages of development. When they
achieve a sense of integrity in life, they garner pride
from their children, students and proteges, and past
accomplishments. With contentment comes a greater
tolerance and acceptance of the decline that naturally
accompanies the aging process. Failure to achieve a
satisfying degree of ego integrity can be accompanied
by despair.
Cohen (in press) has proposed that with increased
longevity and health, particularly for people with
adequate resources, aging is characterized by two
human potential phases. These phases, which
emphasize the positive aspects of the final stages of the
338

life cycle. are termed Retirement/Liberation and
Slrmming Up/Swan Song.
Retirement often is viewed as the most important
life event prior to death. Retirement frequently is
associated with negative myths and stereotypes
(Sheldon et al., 1975; Bass, 1995). Cohen points out,
however, that most people fare well in retirement. They
have the opportunity to explore new interests,
acrivities, and relationships due to retirement's
liberating qualities. In the Retirement/Liberation phase,
new feelings of freedom, courage, and confidence are
experienced. Those at risk for faring poorly are
individuals who typically do not want to retire, who are
compelled to retire because of poor health, or who
experience a significant decline in their standard of
living (Cohen, 1988). In short, the liberating experience
of having more time and an increased sense of freedom
can be the springboard for creativity in later life.
Creative achievement by older people can change the
course of an individual, family, community, or culture.
In the late-life Summing Up/Swan Song phase,
there is a tendency to appraise one's life work, ideas,
and discoveries and to share them with family or
society. The desire to sum up late in life is driven by
varied feelings, such as the desire to complete one's life
work, the desire to give back after receiving much in
life, or the fear of time evaporating. Important
opportunities for creative sharing and expression ensue.
There is a natural tendency with aging to reminisce and
elaborate stories that has propelled the development of
reminiscence therapy for health promotion and disease
prevention. The swan song, the final part of this phase,
connotes the last act or final creative work of a person
before retirement or death.
There is much misunderstanding about thoughts of
death in later life. Depression, serious loss, and
terminal illness trigger the sense of mortality,
regardless of age. Contrary to popular stereotypes,
studies on aging reveal that most older people generally
do not have a fear or dread of death in the absence of
being depressed, encountering serious loss, or having
been recently diagnosed with a terminal illness
(Kastenbaum, 1985). Periodic thoughts of death-not
in the form of dread or angst-do occur. But these are
Older Adults and Mental Health
usually associated with the death of a friend or family
member. When actual dread of death does occur, it
should not be dismissed as accompanying aging, but
rather as a signal of underlying distress (e.g.,
depression). This is particularly important in light of
the high risk of suicide among depressed older adults,
which is discussed later in this chapter.
Coping With Loss and Bereavement
Many older adults experience loss with aging-loss of
social status and self-esteem, loss of physical
capacities, and death of friends and loved ones. But in
the face of loss, many older people have the capacity to
develop new adaptive strategies, even creative
expression (Cohen, 1988, 1990). Those experiencing
loss may be able to move in a positive direction, either
on their own, with the benefit of informal support from
family and friends, or with formal support from mental
health professionals.
  The life and work of William Carlos Williams are
illustrative. Williams was a great poet as well as a
respected physician. In his 60s he suffered a stroke that
prevented him from practicing medicine. The stroke did
not affect his intellectual abilities, but he became so
severely depressed that he needed psychiatric
hospitalization. Nonetheless, Williams, with the help of
treatment for a year, surmounted the depression and for
the next 10 years wrote luminous poetry, including the
Pulitzer Prize-winning Pictures From Bruegel, which
was published when he was 79. In his later life,
Williams wrote about "old age that adds as it takes
away." What Williams and his poetry epitomize is that
age can be the catalyst for tapping into creative
potential (Cohen, 1998a).
Loss of a spouse is common in late life. About
800,000 older Americans are widowed each year.
Bereavement is a natural response to death of a loved
one. Its features, almost universally recognized, include
crying and sorrow, anxiety and agitation, insomnia. and
loss of appetite (Institute of Medicine [IOMI, 1984).
This constellation of symptoms, while overlaPpi%
somewhat with major depression, does not bY itself
constitute a mental disorder. Only when symptoms
persist for 2 months and longer after the loss does the
339

Mental Health: A Report of the Surgeon General
DSM-IV permit a diagnosis of either adjustment
disorder or major depressive disorder. Even though
bereavement of less than 2 months' duration is not
considered a mental disorder, it still warrants clinical
attention (DSM-IV). The justification for clinical
attention is that bereavement, as a highly stressful
event, increases the probability of, and may cause or
exacerbate, mental and somatic disorders.
Bereavement is an important and well-established
risk factor for depression. At least 10 to 20 percent of
widows and widowers develop clinically significant
depression during the first year of bereavement.
Without treatment, such depressions tend to persist,
become chronic, and lead to further disability and
impairments in general health, including alterations in
endocrine and immune function (Zisook & Shuchter,
1993; Zisook et al.,  1994). Several preventive
interventions, including participation in self-help
groups, have been shown to prevent depression among
widows and widowers, although one study suggested
that self-help groups can exacerbate depressive
symptoms in certain individuals [Levy et al., 1993).
These are described later in this chapter.
  Bereavement-associated depression often coexists
with another type of emotional distress, which has been
termed traumatic grief (Prigerson et al., in press). The
symptoms of traumatic grief, although not formalized
as a mental disorder in DSM-IV, appear to be a mixture
of symptoms of both pathological grief and post-
traumatic stress disorder (Frank et al., 1997a). Such
symptoms are extremely disabling, associated with
functional and health impairment and with persistent
suicidal thoughts, and may well respond to pharmaco-
therapy (Zygmont et al., 1998). Increased illness and
mortality from suicide are the most serious
consequences of late-life depression.
  The dynamics around loss in later life need greater
clarification. One pivotal question is why some, in
confronting loss with aging, succumb to depression and
suicide-which, as noted earlier, has its highest
frequency after age 65--while others respond with new
adaptive strategies. Research on health promotion also
needs to identify ways to prevent adverse reactions and
to promote positive responses to loss in later life.
                            1
Meanwhile, despite cultural attitudes that older persons
can handle bereavement by themselves or with support
from family and friends, it is imperative that those who
are unable to cope be encouraged to access mental
health services. Bereavement is not a mental disorder
but, if unattended to, has serious mental health and
other health consequences.
Overview of Mental Disorders in
Older Adults
Older adults are encumbered bg many of the same
mental disorders as are other adults; however, the
prevalence, nature, and course of each disorder may be
very different. This section provides a general overview
of assessment, diagnosis, and treatment of mental
disorders in older people. Its purpose is to describe
issues common to many mental disorders. Subsequent
sections of this chapter provide more detailed reviews
of late-life depression and Alzheimer's disease. Also,
to shed light on the range and frequency of disorders
that impair the mental well-being of older Americans,
the chapter reviews the impact on older adults of
anxiety, schizophrenia, and alcohol and substance
abuse.
Assessment and Diagnosis
Assessment and diagnosis of late-life mental disorders
are especially challenging by virtue of several
distinctive characteristics of older adults. First, the
clinical presentation of older adults with mental
disorders may be different from that of other adults,
making detection of treatable illness more difficult. For
example, many older individuals present with somatic
complaints and experience symptoms of depression and
anxiety that do not meet the full criteria for depressive
or anxiety disorders. The consequences of these
subsyndromal conditions may be just as deleterious as
the syndromes themselves. Failure to detect individuals
who truly have treatable mental disorders represents a
serious public health problem (National Institutes of
Health [NIH] Consensus Development Panel on
Depression in Late Life, 1992).
  Detection of mental disorders in older adults is
complicated further by high comorbidity with other
340

medical disorders. The symptoms of somatic disorders
n,ay mimic or mask psychopathology, making
diagnosis more taxing. In addition, older individuals are
more likely to report somatic symptoms than
psychological  ones, leading to further under-
identification of mental disorders (Blazer, 1996b).
Primary care providers carry much of the burden
for diagnosis of mental disorders in older adults, and,
unfortunately, the rates at which they recognize and
properly identify disorders often are low. With respect
to depression, for example, a significant number of
depressed older adults are neither diagnosed nor treated
in primary care (NIH Consensus Development Panel on
Depression in Late Life, 1992; Unutzer et al., 1997b).
In one study of primary care physicians, only 5.5
percent of internists felt confident in diagnosing
depression, and even fewer (35 percent of the total) felt
confident in prescribing antidepressants to older
persons (Callahan et al., 1992). Physicians were least
likely to report that they felt "very confident" in
evaluating depression in other late-life conditions
(Gal10 et al., in press). Researchers estimate that an
~rnet need for mental health services may be
experienced by up to 63 percent of adults aged 65 years
and older with a mental disorder, based on prevalence
estimates from the Epidemiologic Catchment Area
(ECA) study (Rabins, 1996).
The large unmet need for treatment of mental
disorders reflects patient barriers (e.g., preference for
primary care, tendency to emphasize somatic problems,
reluctance to disclose psychological symptoms),
provider barriers (e.g., lack of awareness of the
manifestations of mental disorders, complexity of
treatment, and reluctance to inform patients of a
diagnosis), and mental health delivery system barriers
(e.g., time pressures, reimbursement policies),
Stereotypes about normal aging also can make
diagnosis and assessment of mental disorders in late
life challenging. For example, many people believe that
"senility" is normal and therefore may delay seeking
care for relatives with dementing illnesses. Similarly,
Patients and their families may believe that depression
and hopelessness are natural conditions of older age,
especially with prolonged bereavement.
Older Adults and Mental Health
Cognitive decline. both normal and pathological.
can be a barrier to effective identification and
assessment of mental illness in late life. Obtaining an
accurate history, which may need to be taken from
family members, is important for diagnosis of most
disorders and especially for distinguishing betlveen
somatic and mental disorders. Normal decline in
short-term memory,  and especially the severe
impairments in memory seen in dementing illnesses
hamper attempts to obtain good patient histories.
Similarly, cognitive deficits are prominent features of
many disorders of late life that make diagnosis of
psychiatric disorders more difficult.
Overview of Prevention
Prevention in mental health has been seen until recently
as an area limited to childhood and adolescence. Now
there is mounting a\vareness of the value of prevention
in the older population. While the body of published
literature is not as extensive as that for diagnosis or
treatment, investigators are beginning to shape new
approaches to pre\,ention. Yet because prevention
research is driven. in part, by refined understanding of
disease etiology-and etiology research itself continues
to be rife with uncertainty-prevention advances are
expected to lag behind those in etiology.
There are man! ways in which prevention models
can be applied to older individuals, provided a broad
view of prevention is used (Lebowitz & Pearson. in
press). Such a broad view entails interventions for
reducing the risk of developing, exacerbating, or
experiencing the consequences of a mental disorder.
Consequently, this section covers primary prevention
(including the pre\.ention of depression and suicide),
treatment-related prevention, prevention of excess
disability, and prevention of premature institutionaliza-
tion. However, many of the research advances noted in
this section have yet to be translated into practice.
Given the frequency of memory complaints and
depression, the tnne may soon arrive for older adu ts ~0
be encouraged to have "mood and memory cneckups"
in the same manner that they are now encouraged to
have physical checkups (N. Abeles, personal
communication. 1998).
341

Mental Health: A Report of the Surgeon General
Primary Prevention
Primary prevention, the prevention of disease before it
occurs, can be applied to late-onset disorders. Progress
in our understanding of etiology, risk factors,
pathogenesis, and the course of mental disorders-
discussed later in this chapter for depression,
Alzheimer's disease, and other conditions-stimulates
and channels the development of prevention
interventions.
The largest body of primary prevention research
focuses on late-life depression, where some progress
has been documented. With other disorders, primary
prevention research is in its infancy. Prevention in
Alzheimer's disease might target individuals at
increased genetic risk with prophylactic nutritional
(e.g., vitamin E), cholinergic, or amyloid-targeting
interventions. Prevention research on late-onset
schizophrenia might explore potential protective
factors, such as estrogen.
Prevention of Depression and Suicide
Depression is strikingly prevalent among older people.
As noted below, 8 to 20 percent of older adults in the
community and up to 37 percent in primary care
settings experience symptoms of depression.
One approach to preventing depression is through
grief counseling for widows and widowers. For
example, participation in self-help groups appears to
ameliorate depression, improve social adjustment, and
reduce the use of alcohol and other drugs of abuse in
widows (Constantino, 1988; Lieberman &
Videka-Sherman, 1986). The efficacy of self-help
groups approximates that of brief psychodynamic
psychotherapy in older bereaved individuals without
significant prior psychopathology (Mat-mar et al.,
1988).  The battery  of psychosocial  and
pharmacological treatments to prevent recurrences of
depression (i.e., secondary prevention) is discussed
later in this chapter under the section on depression.
Depression is a foremost risk factor for suicide in
older adults (Conwell, 1996; Conwell et al., 1996).
Older people have the highest rates of suicide in the
U.S. population: suicide rates increase with age, with
older white men having a rate of suicide up to six times
that of the general population (Kachur et al., 1995;
Hoyert et al., 1999). Despite the prevalence of
depression and the risk it confers for suicide,
depression is neither well recognized nor treated in
primary care settings, where most older adults seek and
receive health care (Unutzer et al., 1997a). Studies
described in the depression section of this chapter have
found that undiagnosed and untreated depression in the
primary care setting plays a significant role in suicide
(Caine et al., 1996). This awareness has prompted the
development of suicide prevention strategies expressly
for primary care. One of the first published suicide
prevention studies, an uncomrolled experiment
conducted in Sweden, suggested that a depression
training program for general practitioners reduces
suicide (Rihmer et al., 1995). Suicide interventions,
especially in the primary care setting, have become a
priority of the U.S. Public Health Service, with lead
responsibility assumed by the Office of the Surgeon
General and the National Institute of Mental Health.
Depression and suicide prevention strategies also
are important for nursing home residents. About half of
patients newly relocated to nursing homes are at
heightened risk for depression (Parmelee et al., 1989).
Treatment-Related Prevention
Prevention of relapse or recurrence of the underlying
mental disorder is important for improving the mental
health of older patients with mental disorders. For
example, treatments that are applied with adequate
intensities for depression (Schneider, 1996) and for
depression in Alzheimer's disease (Small et al., 1997)
may prevent relapse or recurrence. Substantial residual
disability in chronically mentally ill individuals
(Lebowitz et al., 1997) suggests that treatment must be
approached from a longer term perspective (Reynolds
et al., 1996).
  Prevention of medication side effects and adverse
reactions also is an important goal of treatment-related
prevention efforts in older adults. Comorbidity and the
associated polyphatmacy for multiple conditions are
characteristic of older patients. New information on the
genetic basis of drug metabolism and on the action of
drug-metabolizing enzymes can lead to a better
342

understanding of complex drug interactions (Nemeroff
St 31.. 1996). For example, many of the selective
zerotonin reuptake inhibitors compete for the same
metabolic pathway used by beta-blockers, type 1C anti-
;uThythmics, and benzodiazepines (Nemeroff et al.,
1996). This knowledge can assist the clinician in
choosing medications that can prevent the likelihood of
side effects. In addition, many older patients require
antipsychotic treatment for management of behavioral
symptoms in Alzheimer's disease, schizophrenia, and
depression. Although doses tend to be quite low, age
and length of treatment represent major risk factors for
movement disorders (Saltz et al., 1991; Jeste et al.,
1995a). Recent research on older people suggests that
the newer antipsychotics present a much lower risk of
movement disorders, highlighting their importance for
prevention (Jeste et al., in press). Finally, body sway
and postural stability are affected by many drugs,
although there is wide variability within classes of
drugs (Laghrissi-Thode et al., 1995). Minimizing the
risk of falling, therefore, is another target for
prevention research. Falls represent a leading cause of
injury deaths among older persons (IOM, 1999).
Prevention of Excess Disabilify
Prevention efforts in older mentally ill populations also
target avoidance of excessive disability. The concept of
excess disability refers to the observation that many
older patients, particularly those with Alzheimer's
disease and other severe and persistent mental
disorders, are more functionally impaired than would
be expected according to the stage or severity of their
disorder. Medical, psychosocial, and environmental
factors all contribute to excess disability. For example,
depression contributes to excess disability by hastening
functional impairment in patients with Alzheimer's
disease (Ritchie et al., 1998). The fast pace of modem
life. with its emphasis on independence, also
contributes to excess disability by making it more
difficult for older adults with impairments to function
autonomously. Attention to depression, anxiety, and
other mental disorders may reduce the functional
limitations associated with concomitant mental and
somatic impairments. Many studies have demonstrated
Older Adults and Mental Health
that attention to these factors and aggressive
intervention, where appropriate, maximize function
(Lebowitz & Pearson, in press).
Prevention of Premature institutionalization
Another important goal of prevention efforts in older
adults is prevention of premature institutionalization.
While institutional care is needed for many older
patients who suffer from severe and persistent mental
disorders, delay of institutional placement until
absolutely necessary generally is what patients and
family caregivers prefer. It also has significant public
health impact in terms of reducing costs. A randomized
study of counseling and support versus usual care for
family caregivers of patients with Alzheimer's disease
found the intervention to have delayed patients' nursing
home admission by over 300 days (Mittelman et al.,
1996). The intervention also resulted in a significant
reduction in depressive symptoms in the caregivers.
The intervention consisted of three elements:
individual and family counseling sessions, support
group participation, and availability of counselors to
assist with patient crises.
The growing importance of avoiding premature
institutionalization is illustrated by its use as one
measure of the effectiveness of pharmacotherapy in
older individuals. For example, clinical trials of drugs
for Alzheimer's disease have begun using delay of
institutionalization as a primary outcome (San0 et al.,
1997) or as a longer-term outcome in a followup study
after the double-blind portion of the clinical trial ended
(Knopman et al., 1996).
Overview of Treatment
Treatment of mental disorders in older adults
encompasses pharmacological interventions, electro-
convulsive therapy, and psychosocial interventions.
While the pharmacological and psychosocial
interventions used to treat mental health problems and
specific disorders may be identical for older and
younger adults, characteristics unique to older adults
may be important considerations in treatment selection.
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Mental Health: A Report of the Surgeon General
Pharmacological Treatment
The special considerations in selecting appropriate
medications for older people include physiological
changes due to aging; increased vulnerability to side
effects, such as tardive dyskinesia; the impact of
polypharmacy;  interactions with other comorbid
disorders; and barriers to compliance. All are discussed
below.
The aging process leads to numerous changes in
physiology, resulting in altered blood levels of certain
medications, prolonged pharmacological effects, and
greater risk for many side effects (Kendell et al., 1981).
Changes may occur in the absorption, distribution,
metabolism, and excretion of psychotropic medications
(Pollock & Mulsant, 1995).
As people age. there is a gradual decrease in
gastrointestinal motility, gastric blood flow, and gastric
acid production (Greenblatt et al., 1982). This slows the
rate of absorption, but the overall extent of gastric
absorption is probably comparable to that in other
adults. The aging process is also associated with a
decrease in total body water, a decrease in muscle
mass, and an increase in adipose tissue (Borkan et al.,
1983). Drugs that are highly lipophilic, such as neuro-
leptics, are therefore more likely to be accumulated in
fatty tissues in older patients than they are in'younger
patients.
The liver undergoes changes in blood flow and
volume with age. Phase I metabolism (oxidation,
reduction,  hydrolysis) may diminish or remain
unchanged, while phase II metabolism (conjugation
with an endogenous substrate) does not change with
aging. Renal blood flow, glomerular surface area,
tubular function, and reabsorption mechanisms all have
been shown to diminish with age. Diminished renal
excretion may lead to a prolonged half-life and the
necessity for a lower dose or longer dosing intervals.
Pharmacodynamics, which refers to the drug's
effect on its target organ, also can be altered in older
individuals. An example of aging-associated pharmaco-
dynamic change is diminished central cholinergic
function contributing to increased sensitivity to the
anticholinergic effects of many neuroleptics and
antidepressants in older adults (Molchan et al., 1992).
Because of the pharmacokinetic and pharmaco-
dynamic concerns presented above, it is often
recommended that clinicians "start low and go slow"
when prescribing new psychoactive medications for
older adults. In other words, efficacy is greatest and
side effects are minimized when initial doses are small
and the rate of increase is slow. Nevertheless, the
medication should generally be titrated to the regular
adult dose in order to obtain the full benefit. The
potential pitfall is that, because of slower titration and
the concomitant need for more frequent medical visits,
there is less likelihood of oldec adults receiving an
adequate dose and course of medication.
Increased Risk of Side Effects
Older people encounter an increased risk of side
effects, most likely the result of taking multiple drugs
or having higher blood levels of a given drug. The
increased risk of side effects is especially true for
neuroleptic agents, which are widely prescribed as
treatment for psychotic symptoms, agitation, and
behavioral symptoms. Neuroleptic side effects include
sedation, anticholinergic toxicity (which can result in
urinary retention, constipation, dry mouth, glaucoma,
and confusion), extrapyramidal symptoms (e.g., parkin-
sonism,  akathisia,  and dystonia), and tar-dive
dyskinesia. Chapter 4 contains more detailed
information about the side effects of neuroleptics.
Tardive dyskinesia is a frequent and persistent side
effect that occurs months to years after initiation of
neuroleptics. In older adults, tardive dyskinesia
typically entails abnormal movements of the tongue.
lips, and face. In a recent study of older outpatients
treated with conventional neuroleptics the incidence of
tardive dyskinesia after 12 months of neuroleptic
treatment was 29 percent of the patients. At 24 and 36
months, the mean cumulative incidence was 50.1
percent and 63.1 percent, respectively (Jeste et al.,
1995a). This study demonstrates the high risk of tardive
dyskinesia in older patients even with low doses of
conventional neuroleptics. Studies of younger adult
patients reveal an annual cumulative incidence of
tardive dyskinesia at 4 to 5 percent (Kane et al., 1993).
344

Unlike conventional neuroleptics, the newer
atypical ones,  such as clozapine, risperidone,
olanzapine, and quetiapine, apparently confer several
advantages with respect to both efficacy and safety.
These drugs are associated with a lower incidence of
extrapyramidal symptoms than conventional neuro-
leptics are. For clozapine. the low risk of tardive
dyskinesia is well established (Kane et al., 1993). The
incidence of tar-dive dyskinesia with other atypical
antipsychotics is also likely to be lower than that with
conventional neuroleptics because extrapyramidal
symptoms have been found to be a risk factor for
tardive dyskinesia in older adults (Saltz et al., 1991;
Jeste et al., 1995a). The determination of exact risk of
tardive dyskinesia with these newer drugs needs
long-term studies. '
Polypharmacy
In addition to the effects of aging on pharmacokinetics
and pharmacodynamics and the increased risk of side
effects, older individuals with mental disorders also are
more likely than other adults to be medicated with
multiple  compounds,  both prescription and
nonprescription (i.e., polypharmacy). Older adults (over
the age of 65) fill an average of 13 prescriptions a year
(for original or refill prescriptions), which is
approximately three times the number filled by younger
individuals (Chrischilles et al., 1992). Polypharmacy
greatly complicates effective treatment of mental
disorders in older adults. Specifically, drug-drug
interactions are of concern, both in terms of increasing
side effects and decreasing efficacy of one or both
compounds.
Treatment Compliance
Compliance with the treatment regimen also is a special
concern in older adults, especially in those with
moderate or severe cognitive deficits. Physical
problems, such as impaired vision, make it likely that
instructions may be misread or that one medicine may
be mistaken for another. Cognitive impairment may
also make it difficult for patients to remember whether
or not they have taken their medication. Although in
general. older patients are more compliant about taking
Older Adults and Mental Health
psychoactive medications than other types of drugs
(Cooper et al., 1982), when noncompliance does occur,
it may be less easily detected, more serious, less easily
resolved, mistaken for symptoms of a new disease, or
even falsely labeled as "old-age" symptomatology.
Accordingly, greater emphasis must be placed on strict
compliance by patients in this age group (Lamy et al.,
1992). Medication noncompliance takes different forms
in older adults, that is, overuse and abuse, forgetting,
and alteration of schedules and doses. The most
common type of deliberate noncompliance among older
adults may be the underuse of the prescribed drug.
mainly because of side effects and cost considerations.
Factors that contribute to medication noncompliance in
older patients include inadequate information given to
them regarding the necessity for drug treatment,
unclear  prescribing directions, suboptimal
doctor-patient relationship, the large number of times
per day drugs must be taken, and the large number of
drugs that are taken at the same time (Lamy et al.,
1992). Better compliance may be achieved by giving
simple instructions and by asking specific questions to
make sure that the patient understands directions.
Psychosocial Interventions
Several types of psychosocial interventions have
proven effective in older patients with mental disorders,
but the research is more limited than that on
pharmacological interventions (see Klausner &
Alexopoulos, in press). Both types are frequently used
in combination. Most of the research has been
restricted to psychosocial treatments for depression,
although, as discussed below, there is mounting interest
in dementia. For other mental disorders, psychosocial
interventions found successful for younger adults are
often tailored to older people in the practice setting
without the benefit of efficacy research.
Despite the relative paucity of research, psycho-
social interventions may be preferred for some older
patients, especially those who are unable to tolerate, or
prefer not to take, medication or who are confronting
stressful situations or low degrees of social support
(Lebowitz et al., 1997). The benefits of psychosocial
interventions are likely to assume greater prominence
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Mental Health: A Report of the Surgeon General
as a result of population demographics: as the number
of older people grows, progressively more older people
in need of mental health treatment-especially the very
old-are expected to be suffering from greater levels of
comorbidity or dealing with the stresses associated with
disability. Psychosocial interventions not only can help
relieve the symptoms of a variety of mental disorders
and related problems but also can play more diverse
roles: they can help strengthen coping mechanisms,
encourage (and monitor) patients' compliance with
medications, and promote healthy behavior (Klausner
& Alexopoulos, in press).
New approaches to service delivery are being
designed to realize the benefits of established psycho-
social interventions. Many older people are not
comfortable with traditional mental health settings,
partially as a result of stigma (Waters, 1995). In fact,
many older people prefer to receive treatment for
mental disorders by their primary care physicians, and
most older people do receive such care in the primary
care setting (Brody et al., 1997; Unutzer et al., 1997a).
Since older people show willingness to accept
psychosocial interventions in the primary care setting,
new models are striving to integrate into the primary
care setting the delivery of specialty mental health
services. The section of this chapter on service delivery
discusses new models in greater detail.
Gap Between Efficacy and Effectiveness
A problem common to both pharmacological and
psychosocial interventions is the disparity between
treatment efficacy, as demonstrated in randomized
controlled clinical trials, and effectiveness in real-world
settings. While this problem is certainly not unique to
older people (see Chapter 2 for a broader discussion of
the problem), this problem is especially significant for
older people with mental disorders. Older people are
often undertreated for their mental disorders in primary
care settings (Unutzer et al., 1997a). When they do
receive appropriate treatment, older people are more
likely than other people to have comorbid disorders and
social problems that reduce treatment effectiveness
(Unutzer et al.. 1997a). An additional overlay of
barriers, including financing and systems of care, is
discussed later in this chapter.
Depression in Older Adults
Depression in older adults not only causes distress and
suffering but also leads to impairments in physical,
mental,  and social functioning. Despite being
associated with excess morbidity and mortality,
depression often goes undiagnosed and untreated. The
startling reality is that a substantial proportion of older
patients receive no treatment or inadequate treatment
for their depression in primary care settings, according
to expert consensus (NM Consensus Development
Panel on Depression in Late Life, 1992; Lebowitz et
al., 1997). Part of the problem is that depression in
older people is hard to disentangle from the many other
disorders that affect older people, and its symptom
profile is somewhat different from that in other adults.
Depressive symptoms are far more common than full-
fledged major depression. However, several depressive
symptoms together represent a condition-explained
below as "minor depression"-that can be as disabling
as major depression (Unutzer et al., 1997a). Minor
depression, despite the implications of the term, is
major in its prevalence and impact. Eight to 20 percent
of older adults in the community and up to 37 percent
in primary care settings suffer from depressive
symptoms. Treatment is successful, with response rates
between 60 and 80 percent, but the response generally
takes longer than that for other adults. In addition to
reviewing information on prevalence and treatment,
this section also discusses depression's course, barriers
to diagnosis, interactions with physical disease,
consequences, cost, and etiology.
Diagnosis of Major and "Minor" Depression
The term "major depression" refers to conditions with
a major depressive episode, such as major depressive
disorder, bipolar disorder, and related conditions.
Major depressive disorder, the most common type of
major depression in adults, is characterized by one or
more episodes that include the following symptoms:
depressed mood, loss of interest or pleasure in
activities, significant weight loss or gain, sleep
346

disturbance, psychomotor agitation or retardation,
fatigue,  feelings  of worthlessness, loss of
concentration, and recurrent thoughts of death or
suicide. (For further discussion of the diagnosis of
major depressive disorder, see Chapter 4.) Major
depressive disorder cannot be diagnosed if symptoms
last for less than 2 months after bereavement, among
other exclusionary factors (DSM-IV).
Most older patients with symptoms of depression
do not meet the full criteria for major depression. The
new diagnostic entity of minor depression has been
proposed to characterize some of these patients. "Minor
depression," a subsyndromal form of depression, is not
yet recognized as an official disorder, and DSM-IV
proposes further research on it.
Minor depression is more frequent than major
depression, with 8 to 20 percent of older community
residents displaying symptoms (Alexopoulos, 1997;
Gallo & Lebowitz, 1999). The diagnosis of minor
depression is not yet standardized; the research criteria
proposed in DSM-IV are the same as those for major
depression, but a diagnosis would require fewer
symptoms and less impairment. Minor depression, in
fact, is not thought to be a single syndrome, but rather
a heterogeneous group of syndromes that may signify
either an early or residual form of major depression, a
chronic, though mild, form of depression that does not
present with a full array of symptoms at any one time,
called dysthymia. or a response to an identifiable
stressor (Judd et al., 1994; Pincus & Wakefield-Davis,
1997). Since depression is more difficult to assess and
detect in older adults, research is needed on what
clinical features might help identify older adults at
increased risk for sustained depressive symptoms and
suicide.
Both major and minor depression are associated
with significant disability in physical, social, and role
functioning (Wells et al., 1989). The degree of
disability may not be as great with minor depression,
but because of its higher prevalence, minor depression
is associated with 5 1 percent more days lost from work
than is major depression (Broadhead et al., 1990).
Major and minor depression are associated with high
Older Adults and Mental Health
health care utilization and poor quality of life (see
Unutzer et al.. 1997a, for a review).
Late-Onset Depression
Major or minor depression diagnosed with first onset
later than age 60 has been termed late-onset
depression. Late-onset depression is not a diagnosis;
rather, it refers to a subset of patients with major or
minor depression whose later age at first onset imparts
slightly different clinical characteristics, suggesting the
possibility of distinct etiology. Late-onset depression
shares many clinical characteristics with early-onset
depression, yet some distinguishing features exist.
Patients with late-onset depression display greater
apathy (Krishnan et al., 1995) and less lifetime
personality dysfunction (Abrams et al., 1994).
Cognitive deficits may be more prominent, with more
impaired executive and memory functioning (Salloway
et al., 1996) and greater medial temporal lobe
abnormalities on magnetic resonance imaging, similar
to those seen in dementia (Greenwald et al., 1997).
Other studies, however, have shown no differences in
cognition between patients with late- and early-onset
depression (Holroyd & Duryee. 1997). The risk of
recurrence of depression is relatively high among
patients with onset of depression after the age of 60
(Reynolds, 1998).
Risk factors for late-onset depression, based on
results of prospective studies, include widowhood
(Bruce et al., 1990; Zisook & Shuchter, 1991; Harlow
et al., 1991; Mendes de Leon et al., 1994), physical
illness (Cadoret & Widmer, 1988; Harlow et al., 1991:
Bachman et al., 1992), educational attainment less than
high school (Wallace & O'Hara. 1992; Gallo et al..
1993),impaired functional status (Bruce &Hoff, 1994)
and heavy alcohol consumption (Saunders et al., 199 1).
Prevalence and Incidence
Estimates of the prevalence of major depression vary
widely, depending on the definition and the procedure
used for counting persons with depression (Gallo &
Lebowitz, 1999). Researchers applying DSM criteria
for major depression have found 1-yearU.S. prevalence
rates of about 5 percent or less in older people (Gurland
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Mental Health: A Report of the Surgeon General
et al., 1996). The prevalence of major depression
declines with age, while depressive symptoms increase
(symptoms that now might warrant classification as
minor depression). Romanoski and colleagues, on the
basis of psychiatric interviews of adults in the
Baltimore Epidemiologic Catchment Area, showed that
major depression declined with advancing age
(Romanoski et al., 1992). Prevalence estimates derived
from symptom scales are consistent with the clinical
impression that prevalence of depressive symptoms
increases with advancing age. Depressive symptoms
and syndromes have been identified in 8 to 20 percent
of older community residents (Alexopoulos, 1997;
Gallo & Lebowitz, 1999) and 17 to 35 percent of older
primary care patients (Gurland et al., 1996).
  Several incidence studies based on DSM criteria
reflect a similar pattern of decline in rates of major
depression with advancing age (Eaton et al., 1989;
Eaton et al., 1997). The 13-year followup of the
participants of the Baltimore Epidemiologic Catchment
Area (ECA) sample revealed, however, that the
distribution of the incidence of DSM-based major
depression across the life span was bimodal, with a
primary peak in the fourth decade and a secondary peak
in the sixth decade (Eaton et al., 1997). In contrast to
studies based on DSM criteria, several incidence
studies report increased rates of depressive symptoms
with age. A Swedish study reported that rates of
depressive symptoms were highest in the older age
groups and that rates of depression had increased in the
interval from 1947-1957 to 1957-1972 (Hagnell et al.,
1982). Incidence studies reveal an increased risk of
depression among women as they age, consistent with
findings based on prevalence surveys (Hagnell et al.,
1982; Eaton et al., 1989; Gallo et al., 1993).
Thus, both prevalence and incidence studies that
rely on DSM-based diagnosis of major depression
suggest a decline with age, whereas symptom-based
assessment studies show increased rates of depression
among older adults, especially women. Evidence that
older adults are less likely than younger persons to
report feelings of dysphoria (i.e., sadness. unhappiness,
or irritability) suggests that the standard criteria for
depression may be more difficult to apply to older
adults (Gallo et al., 1994) or that older adults are
disinclined to report such feelings.
Other mood disorders, such as dysthymia, bipolar
disorder, and hypomania,' also are present in older
individuals. Little difference has been found in the
prevalence of affective disorders between African
Americans and whites over the age of 65 (Weissman et
al., 199 1). The prevalence of bipolar disorder among
people aged 65 and over is reportedly less than 1
percent (Robins & Regier, 1991). Approximately 5 to
10 percent of older patients presenting with mood
disorders are manic or hypomanic (Yassa et al., 1988).
However, these mood disorders will not be the focus of
this section of the report, as they are much less
common in older adults than depression.
Barriers to Diagnosis and Treatment
The underdiagnosis and undertreatment of depression
in primary care represent a serious public health
problem (NIH Consensus Development Panel on
Depression in Late Life, 1992). One study found that
only about 11 percent of depressed patients in primary
care received adequate antidepressant treatment (in
terms of dose and duration of pharmacotherapy), while
34 percent received inadequate treatment and 55
percent received no treatment (Katon et al., 1992).
There are many barriers to the diagnosis of
depression in late life. Some of these barriers reflect the
nature of the disorder: depression occurs in a complex
medical and psychosocial context. In the elderly, the
signs and symptoms of major depression are frequently
attributed to  "normal aging," atherosclerosis,
Alzheimer's disease, or any of a host of other age-
associated afflictions. Psychosocial antecedents such as
loss, combined with decrements in physical health and
sensory impairment, can also divert attention from
clinical depression.
Another reason for the underdiagnosis is that older
patients are less likely to report symptoms of dysphoria
and worthlessness,  which are often considered
hallmarks of the diagnosis of depression. The
' Hypomania is marked by abnormally elevated mood, but the
symptoms are not severe enough for mania (see Chapter 4).
348

consequences of underdiagnosis of this subset of
patients can be severe. On the basis of a followup of
older adults in the Baltimore Epidemiologic Catchment
Area sample, persons with depressive symptoms (e.g.,
sleep and appetite disturbance) without sadness (e.g.,
hopelessness, worthlessness, thoughts of death, wanting
to die, or suicide) were at increased risk for subsequent
functional impairment, cognitive impairment,
psychological distress, and death over the course of the
13-year interval (Gallo et al., 1997).
Other barriers to diagnosis are patient related.
Depression can and frequently does amplify physical
symptoms, distracting patients' and providers' attention
from the underlying depression; and many older
patients may deny psychological symptoms of
depression or refuse to accept the diagnosis because of
stigma. This appears to be particularly the case with
older men, who also have the highest rates of suicide in
later life (Hoyert et al., 1999).
Provider-related factors also appear to play a role
in underdetection of depression and suicide risk.
Providers may be reluctant to inform older patients of
a diagnosis of depression, owing to uncertainty about
diagnosis, reluctance to stigmatize, uncertainty about
optimal treatment,  concern about medication
interactions or lack of access to psychiatric care, and
continuing concern about the effectiveness and cost-
effectiveness of treatment intervention (NIH Consensus
Development Panel on Depression in Late Life, 1992;
Unutzer et al., 1997a).
Societal stereotypes about aging also can hamper
efforts to identify and diagnose depression in late life.
Many people believe that depression in response to the
loss of a loved one, increased physical limitations, or
changing societal role is an inevitable part of aging.
Even physicians appear to hold such stereotyped views.
Three-quarters of physicians in one study thought that
depression "was understandable" in older persons
(Gallo et al., in press), consistent with other studies
(Bartels et al., 1997). Suicidal thoughts are sometimes
considered a normal facet of old age. These mistaken
beliefs can lead to underreporting of symptoms by
patients and lack of effort on the part of family
members to seek care for patients.
Older Adults and Mental Health
Finally, the health care system itself is increasingly
restricting the time spent in patient care, forcing mental
health concerns to compete with comorbid general
medical conditions. Primary care physicians often
report feeling too pressured for time to investigate
depression in older people (Glasser & Gravdal, 1997).
Given the inseparability of mental and general health in
later life particularly, this trend is worrisome.
Course
Across the life span, the course of depression is marked
by recurrent episodes of depression followed by
periods of remission. In late life, the course of
depression tends to be more chronic than that in
younger adults (Alexopoulos & Chester, 1992;
Callahan et al., 1994; Cole & Bellavance, 1997). This
means that recurrences extend for longer duration,
while intervals of remission are shorter. It also means
that cycles of recurrence and remission persist over a
longer period of time. Patients' response to treatment is
highly variable, and the determinants of treatment
response and its temporal profile are the subjects of
intense research (Reynolds & Kupfer, 1999). A slower,
less consistent response, which suggests a higher
probability of relapse, is related to older age, presence
of acute and chronic stressors, lower levels of
perceived social support, higher levels of pretreatment
anxiety, and greater biologic dysregulation as reflected
in higher levels of rapid eye movement sleep (Dew et
al., 1997). The temporal profile of the initial treatment
response also may provide important clues about which
patients are likely to fare well on maintenance
treatment and which ones are likely to have a brittle
treatment response and stormy long-term course.
A recent update of the NIH Consensus Develop-
pment Conference on the Diagnosis and Treatment of
Late-Life Depression emphasized the need for more
data to guide long-term treatment planning, especially
in patients 70 years and older with major depression
(Lebowitz et al., 1997). Little is currently known about
differences, if any, in speed and rate of remission,
relapse, recovery, and recurrence in patients aged 60 to
69 and those aged 70 and above. In a study at the
University of Pittsburgh, two groups of patients (ages
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Mental Health: A Report of the Surgeon General
60 to 69 and 70+) showed comparable times to
remission and recovery, as well as similar absolute
rates of remission during acute therapy, relapse during
continuation therapy, and recovery. However, patients
aged 70 and older experienced a significantly higher
rate of recurrence during the first year of maintenance
therapy (Reynolds.  1998). Thus, the course of
depression and its interaction with treatment are
influenced by age. This highlights the importance of
research targeted at older age groups instead of reliance
on extrapolations from younger patients.
Interactions With Somatic Ihess
Late-life mental disorders are often detected in
association with somatic illness (Reynolds & Kupfer,
1999). The prevalence of clinically significant
depression in later life is estimated to be highest-
approximately 25 percent-among those with chronic
illness. especially with ischemic heart disease, stroke,
cancer, chronic lung disease, arthritis, Alzheimer's
disease, and Parkinson's disease (Borson et al., 1986;
Blazer, 1989; Oxman et al., 1990; Callahan et al., 1994;
Beekman et al., 1995; Borson, 1995).
The relationship between somatic illness and
mental disorders is likely to be reciprocal, but the
mechanisms are far from understood. Biological and
psychological factors are thought to play a role
(Unutzer et al., 1997a). The nature and course of
late-life depression can be greatly affected by the
coexistence of one or more other medical conditions.
Insomnia and sleep disturbance play a large role in
the clinical presentation of older depressed patients.
Sleep complaints over time in community-residing
older people have been found to vary with the intensity
of depressive symptoms (Rodin et al., 1988). Sleep
disturbances in older men and women have also been
recently linked to poor health, depression, angina.
limitations in activities of daily living, and chronic use
of benzodiazepines (Newman  et al.,  1997).
Furthermore, persistent or residual sleep disturbance in
older patients with prior depressive episodes predicts a
less successful maintenance response to
pharmacotherapy (Buysse et al., 1996). The prevalence
of chronic. primary insomnia in older adults is
estimated at 5 to 10 percent (Ohayon et al., 1996).
Relatively little is known about the etiology or
pathophysiology of chronic primary insomnia and why
it constitutes a risk factor for depression in older adults.
An important issue for further research is whether
effective treatment for chronic insomnia could prevent
the subsequent development of clinical depression in
midlife and later.
Consequences of Depression
The most serious consequence of depression in later
life-especially untreated or inadequately treated
depression-is increased mortality from either suicide
or somatic illness. Older persons (65 years and above)
have the highest suicide rates of any age group. The
suicide rate for individuals age 85 and older is the
highest, at about 21 suicides per 100,000, a rate almost
twice the overall national rate of 10.6 per 100,000
(CDC, 1999). The high suicide rate among older people
is largely accounted for by white men, whose suicide
rate at age 85 and above is about 65 per 100,000 (CDC,
1999). Trends from 1980 to 1992 reveal that suicide
rates are increasing among more recent cohorts of older
persons (Kachur et al., 1995). Since national statistics
are unlikely to include more veiled forms of suicide,
such as nursing home residents who stop eating,
estimates are probably conservative.
  Suicide in older adults is most associated with late-
onset depression: among patients 75 years of age and
older, 60 to 75 percent of suicides have diagnosable
depression (Conwell, 1996). Using a "psychological
autopsy," Conwell and coworkers investigated all
suicides within a geographical region and found that
with increasing age, depression was more likely to be
unaccompanied by other conditions such as substance
abuse (Conwell et al., 1996). While thoughts of death
may be developmentally expected in older adults,
suicidal thoughts are not. From a stratified sample of
primary care patients over age 60, Callahan and
colleagues estimated the prevalence of specific suicidal
thoughts at 0.7 to 1.2 percent (Callahan et al., 1996b).
Unfortunately, no demographic or clinical variables
distinguished depressed suicidal patients from
depressed nonsuicidal patients (Callahan et al., 1996b).
350