Bipolar Disorder in Later Life
Older adults with bipolar disorder constitute a growing population of people with serious mental illness and considerable need for treatment. In the past few years, we have become increasingly aware that the notion that bipolar disorder in late life “burns out” or resolves over a period of decades is a myth. On the contrary, geriatric bipolar disorder is associated with substantial morbidity and mortality and poor psychosocial outcomes. As the population in general — and in industrialized nations in particular — ages and as our skills for recognizing and treating bipolar disorder increase, the challenge of managing manic–depressive illness in older adults becomes a burning issue. That is why this excellent book is so timely and relevant. The editors have succeeded in gathering a group of distinguished psychiatrists, gerontologists, and public health experts who precisely summarize current knowledge and unmet needs in the area of bipolar disorder in older patients.
The book acknowledges the multiple challenges that, if resolved, would ensure optimal outcomes for older adults with bipolar disorder. The 13 chapters are organized into four parts, although it is unclear why they were not separated into just two parts — one on assessment and the other on treatment. The first part of the book contains three chapters. In the first chapter, the book’s editors, Martha Sajatovic and Frederic C. Blow, explain changes in patterns of diagnosis over the course of life, distinctions between early and late onset of illness, and changes in clinical features that are associated with aging.
Chapter 2, by Robert C. Young, Katherine Peasley-Miklus, and Herbert C. Schulberg, deals with assessment and rating scales and their use in older patients. It should be noted that Young is the first author of a landmark publication on the most successful scale we have for rating mania. Chapter 3 covers the comprehensive assessment of persons with bipolar disorder in institutional settings and supports the use of a battery of instruments for geriatric assessment that were selected by an international research collaborative.
Part II of the book deals with treatment and includes chapters on the management of late-onset bipolar disorder and secondary mania; biologic treatments, including mood stabilizers, antipsychotic drugs, antidepressant drugs, and electroconvulsive therapy; psychosocial interventions (as described in the evocative subtitle of chapter 6, “Navigating Terra Incognita"); and treatment adherence, a major issue with elderly patients. Part III returns to epidemiology and includes discussions of the complexity of bipolar disorder in later life due to coexisiting conditions that are caused by somatic conditions and substance abuse. The issue of coexisting medical conditions is critical, and in her chapter on this topic, Helen C. Kales covers the whole range of conditions that are commonly seen in older adults with bipolar disorder, including diabetes, cardiovascular disease, and dementia. She also discusses their implications for pharmacotherapy, including a brief discussion of drug interactions. The last chapter in part III concerns cultural aspects of the diagnosis and treatment of bipolar disorder, with little emphasis on aging. The three chapters in part IV are devoted to the delivery of specialized care, quality of care, evidence-based medicine, and ethical issues in bipolar disorder research. A major problem discussed in this section is the exclusion of the elderly from clinical trials.
Bipolar disorder was a neglected area of research for many decades. The individual characteristics and needs of patients who have bipolar disorder throughout their lives are still inadequately studied and poorly understood. More questions than answers are provided in this book, but this reflects the current state of the field. Nevertheless, we are left with the hope that many questions will be efficiently addressed in the coming years by the editors and authors of this book and by other members of the scientific community, who now have the opportunity to become more aware of the huge daily challenge of the management of bipolar disorder in older adults.
Eduard Vieta, M.D., Ph.D.
Hospital Clinic, University of Barcelona
08036 Barcelona, Spain
Edited by Martha Sajatovic and Frederic C. Blow. 257 pp., illustrated. Baltimore, Johns Hopkins University Press, 2007. $50. ISBN 978-0-8018-8581-5.
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