Bipolar Disorder in Later Life

By Shulman, Kenneth | Canadian Journal of Psychiatry, July 2008 | Go to article overview

Bipolar Disorder in Later Life


Shulman, Kenneth, Canadian Journal of Psychiatry


Bipolar Disorder Bipolar Disorder in Later Life Martha Sajatovic and Frederic C Blow, editors. Baltimore (MD): The Johns Hopkins University Press; 2007. 257 p. US$50.00

Reviewer rating: Excellent

Review by Kenneth Shulman, MD

Toronto, Ontario

One of the chapters in this comprehensive and timely text on bipolar disorder in later life uses the apt subtitle, "Navigating Terra Incognita." This is an underlying theme to the entire text, as the evidence base for understanding the nature and management of bipolar disorders in later life is very limited. Nonetheless, the authors have compiled this text because late-life bipolar disorders are associated with poor social outcomes, significant medical comorbidities, and increased health care costs.

The book is carefully edited by Martha Sajatovic, a well-known American researcher in late-life bipolar disorders, and Frederic Blow, director of the National Serious Mental Illness Treatment Research and Evaluation Center in the Veterans Affairs System in Michigan. They bring together a vast amount of research and clinical experience, directly and indirectly related to bipolar disorders in older adults. The text is divided into 4 sections including: epidemiology and assessment, treatment, complexity and comorbidity, and specialized care delivery and research.

One of the prominent themes and issues that emerge is the question of burnout and age of onset of later life bipolar disorders. The authors argue that these disorders do not burnout, but remain a significant concern in later life. Really, the question is: Do early onset bipolar disorders burnout as they grow old? For this the evidence is quite mixed depending on whether one uses an outpatient or inpatient sample. However, the authors make the valid point that the burden of bipolar disorder in old age does not burnout or diminish. Sajatovic and colleagues used a large Veteran's Affairs database in the United States to document the heavy cost of health services by older bipolar patients, including their medical and psychiatric comorbidities. Curiously, they found that early onset patients in the Veteran's Affairs database seem to create a greater burden than late onset cases. Just why this should be adds yet another important and unanswered question to the many posed in this book. Age of onset remains an important variable that helps to identify different factors relevant to the pathogenesis and etiology of bipolar disorders across the lifespan.

Perhaps the best chapter in the book is the one written by the editors themselves: "Epidemiology of Bipolar Disorder in Later Life." This is a concise and well-written chapter that addresses gender differences, outcomes in the use of health services, clinical presentation, comorbidity, barriers to care, and treatment. Each of these subsections is addressed more completely in separate chapters.

The book highlights numerous interesting and unique approaches to understanding bipolar disorders. …

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