Psychosocial interventions and successful aging: new paradigms for improving outcome for older schizophrenia patients?

Research on schizophrenia in older persons remains a critically neglected area. Although about one in seven persons with schizophrenia are age 65 or older, only 1% of the current literature on schizophrenia is dedicated to issues related to aging. Moreover, the number of older persons with schizophrenia will double over the next two decades. It is an encouraging sign, however, that several areas that received limited attention in the past are now the focus of interest in the research community. This special issue of the American Journal of Geriatric Psychiatry is appropriately timed to highlight several of these topics. The publication of this issue marks four years since the publication of the first special issue of the Journal on late-life schizophrenia. In their editorial in that issue, Jeste and Nasrallah highlighted broad differences in schizophrenia in younger and older persons. They also challenged investigators to address a number of questions in future research. The four original research articles in this special issue shed light on some of these questions. Readers will also appreciate that these four articles are strengthened by their use of large samples, multiracial samples in the American studies, and theoretical multivariate models in two of the articles. Ostling et al. present data from their work in Gothenburg, Sweden, where they have conducted a large population-based study of the prevalence of psychotic symptoms among a nondemented population of 95-year-olds. The proportion of “very old” persons is expanding rapidly, and there is a paucity of epidemiologic data concerning this population. This seminal study is the first to gather data on the prevalence of psychotic disorders in this age group. Their findings are enhanced by the fact that they conducted interviews with subjects as well as with persons in their immediate social network. Their finding of prevalence rates of psychosis and paranoid ideation of 7.4% and 10.4%, respectively, indicates that such symptoms are widespread and may have important public health implications. Earlier studies had found prevalence rates of psychotic symptoms and paranoid ideation of up to 10% among older community-dwelling adults. In the work of Ostling et al. as well as of other investigators, few persons met the diagnostic criteria of a mental disorder. However, psychotic and paranoid symptoms were associated with other signs of distress, including depression and lower daily functioning. Hence, such symptoms may not necessarily be benign. A thorny issue is whether psychotic symptoms produce depression and other concomitant symptoms or whether the psychotic symptoms represent an expression of psychiatric distress. Their finding of a 2% rate of schizophrenia in the study also raises the question as to when these individuals developed the disorder. An interesting issue is whether schizophrenia can arise at any age. Indeed, a case report by Cervantes et al. described new onset at age 100. Depression in older patients with schizophrenia has received attention in the literature and has been identified by previous studies as a potentially remediable source of comorbidity. In this issue, two arti-