Richard Berlin, MD, shares his poem "Contemplating Retirement," which will appear in the October 2022 issue of 

embrace. I let my mind wander to new meds

the effort of starting with someone new—

and rapport, history-taking’s excavation,

responsibility’s weight, all the risks,

Last week I changed my voicemail greeting

to declare I’m not accepting new patients,

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"Patients get better, treatments end, openings appear in my schedule and I leave them open..."


"Contemplating Retirement"

 is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

In Memoriam: The Healing Force of Pharoah Sanders’ Music

,” I celebrated the psychological healing of his music in my eulogy of the jazz saxophonist Pharoah Sanders. I do not know if he ever played in Russia, but the history of jazz there goes back and forth between such freedom of expression and suppression.

More on King Charles III, Psychiatry, Religion, and Spirituality

Considering National and Personal Character in Russia’s Invasion of Ukraine

Tomorrow, October 1st, as written about in the September 27th issue of the 

 article “When Russia Said ‘Da’ to Jazz,” is the 100th anniversary of the coming of jazz to Russia.

 It is being celebrated there under the auspices of Russia’s own native saxophonist, Igor Butman. They are reconstructing the original concert, which set off a period of jazz popularity in Russia. This period lasted until World War II, after which Stalin cracked down on all jazz as the Cold War with the United States heated up. Some intermittent thawing occurred, especially via the shortwave radio programs of Voice of America.

In the meanwhile, a courageous jazz underground of more avant grade music, like that of Pharoah Sangers, grew in the 1970s and 80s, culminating in open governmental acceptance after the Soviet Union dissolved in 1991. Now, under Putin. It will be interesting to see what happens to jazz after this anniversary. Perhaps jazz is a good measuring stick for the degree of authoritarian leadership in a country.

Why is this relevant to psychiatry? Freedom of thought and expression is certainly at risk in the ever-growing cultish groups and conspiracy theories online and offline in the United States and elsewhere. Thankfully, there are formalized methods, such as the BITE (Behavior, Information, Thought, Emotion) Model, to address this problem, as discussed in the May 22, 2022, 

™ interview with Steven Hassan, PhD, titled “

As its essence, isn’t psychiatry an improvisatory quest for more freedom of mind and relationships, so ably represented in jazz music?

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Hasse JE. When Russia said ‘da’ to jazz. 

. September 27, 2022. Accessed Spetember 30, 2022. 

https://www.wsj.com/articles/cultural-commentary-russia-jazz-100-anniversary-joseph-stalin-valentin-parnakh-sam-wooding-frank-withers-duke-ellington-garvin-bushell-sidney-bechet-eddit-rosner-oleg-ludstrem-cyril-moshkow-leonid-utyosov-benny-goodman-earl-hines-thad-jones-mel-lewis-igor-butman-11664316734

Articles

Is jazz a good litmus test for Russia’s leadership? 

The Freedom and Suppression of Jazz in Russia

A safety plan is a critical evidence-based intervention that can reduce suicidal behavior, either as a standalone intervention or as part of a comprehensive treatment plan.

 The purpose of the safety plan is to provide patients who are at heightened risk for suicide with concrete, actionable coping strategies they can use during a suicidal crisis to decrease their risk of attempting suicide. In addition to its practical and intended use, a safety plan also conveys hope by demonstrating to an individual with suicidal ideation that there are more effective ways of managing their problems.

A safety plan is different from a no-suicide contract. Research has shown that no-suicide contracts are ineffective and can lead patients to withhold information about suicidal thoughts and behaviors from their providers.

At the beginning of treatment, or if a previously non-suicidal patient begins reporting suicidal risk factors, it is important to determine risk for suicide by conducting a comprehensive suicide risk assessment. This may include patients who have experienced previous episodes of suicidal ideation or behavior because, when the previous suicide risk is greater than the current risk, it is a better predictor of suicidal behavior.

 Safety planning should then be conducted immediately upon determining that a patient is at heightened risk for suicide.

As with all interventions, clinicians should provide patients with a rationale for safety planning. If possible, clinicians can emphasize the collaborative nature of the intervention by sitting next to the patient when completing the plan. Clinicians should start by eliciting warning signs that risk for suicide is increasing. This helps patients gain awareness of when they need to access and use their safety plan. It is typically easier for patients to implement safety plan coping strategies at the early stages of a suicidal crisis than it is after the episode escalates in intensity. Noticing warning signs can help patients begin using coping strategies so that a more severe crisis and related suicidal behavior are prevented.

Once the clinician and patient have a good understanding of the patient’s warning signs, the first section of the safety plan can be completed. Warning signs may include feelings of hopelessness or irritability; thoughts like, “I’ll always be alone”; behaviors like arguing with a parent; and/or physiological sensations such as intense pain from a chronic medical condition. They can also include events, such as the anniversary of the death of a loved one.

The next part of the safety plan involves identifying different categories of coping strategies patients will use once they have recognized that they are at heightened risk for suicide. The safety plan begins with internal coping strategies the patient can use without assistance from others and progresses through incrementally more intensive strategies the patient can use if the initial strategies are ineffective.

Internal coping strategies typically involve experiences that distract the patient from their suicidal thoughts, emotional distress, or urges by diverting their attention onto other activities, stimuli, or sensations. Clinicians can identify internal coping strategies by asking patients, “What have you done in the past that has been at least a little helpful when you have experienced any of these warning signs?” If the patient has trouble identifying coping strategies, you can make suggestions.

Some patients may benefit from focusing on sensory experiences like listening to music or taking a hot shower. Patients may also engage in a distracting activity, such as going for a walk, watching an entertaining TV show, or playing video games. When completing this section of the safety plan, clinicians should be as specific and detailed as possible. For example, if a patient identifies listening to music as a coping strategy, the clinician should find out exactly which songs or artists the patient finds helpful and how the patient will listen to them (eg, on their phone).

After completing each coping strategy section, clinicians elicit feedback from patients. Clinicians should assess how likely it is that the patient will use the strategies in a suicidal crisis and problem solve for any obstacles that may get in the way. A simple way to assess the utility of each part of the plan is to ask, “Thinking about how you feel when in a suicidal crisis, how likely are you to use these strategies on a scale of 0 to 100, where 0 indicates that you will definitely not use these strategies and 100 indicates that you have no doubt that you will use them?” If the patient provides a rating of less than 90, the clinician will need to do some additional work to assess practical problems or beliefs that may be interfering with the patient’s likelihood of using the strategies. This might involve eliminating some strategies and replacing them with other, more helpful ones.

For the next section of the safety plan, patients are asked to identify individuals and social settings that can serve as a distraction during a suicidal crisis. It should be emphasized that these are not individuals the patient is contacting to directly ask for help, but rather individuals who can provide social experiences that can divert the patient’s attention from suicidal thoughts or urges. The identified individuals should be known to be responsive and accessible, and the patient should be explicit about the medium for communication (ie, via phone, via text, or in person).

Patients may also wish to identify social locations they can visit, such as a local park, a coffee shop, or an AA meeting. Many patients find it helpful to be around other people during a suicidal crisis, even if the people are strangers. As with the section on internal coping strategies, clinicians should assess the likelihood that patients will use the strategies in this section before moving on.

Next, the patient will identify individuals that they can contact to directly ask for support. The identified individuals should have a history of being responsive or helpful when the patient has asked them for support in the past. The patient will need to determine whether they feel comfortable explicitly stating that they are having a suicidal crisis, or whether they would prefer to be vague (ie, telling the person they feel “down” or “anxious” instead). If the patient is not sure whether an identified person will be willing and able to help, they can have a conversation with the person in the coming week about their desire to reach out for support if needed. They may even tell the person what they would like them to do if they call on them for support. If the patient is not comfortable having this type of conversation, it may be helpful for the clinician to provide some brief coaching on communication skills and to offer to roleplay the conversation.

Once support people have been identified, clinicians should be explicit about the order in which the patient will contact them and the medium for contact. Finally, the names and phone numbers of the individuals should be added to the safety plan.

If the patient has moved through all the previous coping strategies and is still in suicidal crisis, the final strategy is to contact mental health providers or facilities that can intervene with professional help. Typically, the clinician’s name will be at the top of this section, followed by additional mental health clinicians and trusted medical professionals. Clinicians should be explicit with clients about how emergencies are handled both during and after business hours, whether they have an answering service, or if there is another provider in the practice who may be on call if the patient experiences a crisis after hours.

This section can also include hotline services, like the new mental health crisis number, 988, which is now available in the United States. Finally, patients should designate a local urgent care service or psychiatric emergency room if hospitalization is required. Patients should also determine how they will get to their designated facility (ie, will they call an ambulance or ask a friend or family member to drive them?).

The next step in safety planning is making the patient’s environment safer. Clinicians should focus on reducing the patient’s access to their identified means for suicide. It is important to restrict access to firearms, regardless of whether the patient expresses a desire to use a firearm for suicide. In the United States, approximately half of individuals who commit suicide do so using firearms.

 Having a firearm in the household is also associated with a 5-fold increase in death by suicide.

When asking the patient about their chosen means for suicide, collaboration is key. Often, patients view having access to a means for suicide as a coping strategy in and of itself. A patient may consider a stockpile of pills hidden in a drawer an “escape hatch” they can use if their problems become overwhelming. That patient may then have a negative reaction to the clinician’s suggestion that they turn their medication over to a friend for safekeeping.

Clinicians can be collaborative by asking patients for suggestions to make their environment safer before offering their own suggestions. For instance, a patient may prefer keeping a pill box with 1 week’s worth of medication while a family member has possession of the remaining bottle. A patient who is unwilling to give up their firearm may be willing to store it in a locked safe and give the key to a trusted friend. Clinicians can emphasize that the measures are temporary and will last only until the suicidal crisis is over.

The last component of the safety plan is identifying reasons for living. Clinicians should work with patients to identify at least 1 thing that makes the patient’s life worth living. The simplest way to help patients identify reasons for living is simply to ask, “What is 1 thing that is most important and worth living for?” If patients have difficulty identifying 1 reason for living, clinicians can prompt them by asking about different areas where individuals often find meaning, including relationships, important goals, or religion and spirituality. If the patient is still having trouble identifying a compelling reason for living, the clinician might suggest that even the potential of having a future reason for living, or the possibility that life might seem worthwhile, can also be reasons for living. For example, a young female patient of mine did not have children, but she identified wanting to be a mother sometime in the future as a potential reason for living.

Once the safety plan is complete, the clinician’s work is to increase the likelihood that the patient will actually use it in a suicidal crisis. The clinician will start by asking for general feedback about the safety planning process and whether the patient believes the plan will be helpful. The clinician will then try to uncover obstacles that might get in the way of the patient using the plan when needed.

Sometimes practical problems may get in the way. For example, the patient may not remember to use their plan, particularly when they are in the midst of a suicidal crisis. It is usually a good idea to ask patients to review their safety plan every day, regardless of whether they are feeling suicidal. Clinicians should be explicit with patients about when they will review their plan. Most patients can benefit from reviewing their plan each morning, as this helps keep the plan at the forefront of their minds throughout the remainder of the day. Another obstacle might be the accessibility of the plan. The clinician will want to be sure the patient has access to their plan wherever they are. Patients may wish to take a picture of it with their phone, or to make multiple copies and store them in different locations (ie, in their car, in their desk at work, on a nightstand).

Some patients may express doubt that the plan will be helpful. The clinician can communicate that the safety plan is not meant to solve all their problems—the safety plan is just meant to keep the patient alive so that they can continue to work on more longstanding problems in therapy. The clinician can also stress that the safety plan can evolve and change over time, as the patient determines that some of the strategies are not helpful and learns new strategies in therapy that may be more helpful. The patient just needs to agree to use the plan, regardless of whether they are confident it will be helpful.

Each subsequent session with the patient should begin with a review of the plan and a discussion of any strategies the patient has tried to determine their utility. If a patient outright refuses to use their safety plan, clinicians should consider whether the patient should be referred to a higher level of care.

is a licensed clinical psychologist at the 

Beck Institute for Cognitive Behavior Therapy

is the communications manager at the Beck Institute for Cognitive Behavior Therapy.

1. Nuij C, van Ballegooijen W, de Beurs D, et al. 

Safety planning-type interventions for suicide prevention: meta-analysis

The case against no-suicide contracts: the commitment to treatment statement as a practice alternative

Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients

Suicide case-fatality rates in the United States, 2007 to 2014: a nationwide population-based study

Gun safety management with patients at risk for suicide. 

What is a safety plan, and how can clinicians use it to help patients with suicidal behavior? 

Safety Planning: An Essential Feature of Cognitive Behavior Therapy for Suicide Prevention

I caught a brief interchange of the September 27th “Late Show” when Stephen Colbert was interviewing the well-known foreign war correspondent Clarissa Ward. She seemed to be concluding that Russia has an unusual propensity to tolerate suffering, so that a long war would not be all that psychologically difficult for the country as a whole.

Her comment reminded me of how long Russia was able to hold out, starvation common by the end, to the siege of Leningrad by the German Nazis in World War II. They ultimately shifted the whole tide of the war.

There are many jokes about Russian tolerance for suffering, and the role of vodka in coping with it. Take Woody Allen in his 1975 film “Love and Death,” when the antihero Boris Grushenko said this about human suffering, in a sort of word play like that of the psychiatrist and writer, R.D. Laing:

“To love is to suffer. To avoid suffering one must not love, but then one suffers from not loving. Therefore, to love is to suffer, not to love is to suffer, to suffer is to suffer. To be happy is to love, to be happy then is to suffer but suffering makes one unhappy, therefore to be unhappy one must love or love to suffer or suffer from too much happiness.”

That led me to wonder, too, about the possible commonality of a national character, say “pushy” Americans or “compliant” Canadians or “somber” Scandinavians. As it turns out, whatever research I could find was inconclusive. That also seems to fit the difficulty of describing an individual with one characteristic, like he’s a “good guy” (though I hope that is often said of me!).

As far as individuals go, Vladimir Putin has also been thought to have a high tolerance for pain and suffering. Moreover, the well-regarded expert in political psychiatry, Jerrold Post, MD, once upon a time did analyze Putin’s character, as I discussed right after the Ukrainian invasion began on February 24, 2022 in the column “What Would Dr Post Say about President Putin?”

 Ignoring the American Psychiatric Association’s Goldwater Rule, in a 2015 article in 

, “Putin is ‘Playing Madman’ to Trick the West,” Dr Post said that Putin had a steely surface and would not be bullied like he was in childhood.

In a parallel sort of process, suffering is also common in psychiatric disorders and can be severe and chronic, sometimes with suicide becoming the option to relieve it. But, like Russia in World War II, relief is often ultimately possible and to be hoped for. Clinicians have to remain empathetic to the suffering and keep searching for ways to decrease it.

Occasionally, though, masochistic tendencies psychodynamically produce some perceived enjoyment of the suffering. If Putin and the bulk of Russians have that sort of masochistic suffering, that will add to the challenge of defeating them. The winter may be brutal for both sides. Some negotiated and face-saving settlement seems psychologically indicated.

1. Moffic MS. What would Dr Post say about President Putin? 

https://www.psychiatrictimes.com/view/what-would-dr-post-say-about-president-putin

2. Braw E. Putin is 'Playing the madman' to trick the West. 

. April 1, 2015. Accessed September 29, 2022. 

https://www.newsweek.com/2015/04/10/impeccable-logic-behind-putins-madman-strategy-318529.html

It could be a long and cold winter for Russia…

H. Steven Moffic, MD, discusses restorative justice, or the opportunity for perpetrators to talk about their crimes and reasoning in order to help relieve victims, and maybe relieve the perpetrators of guilt as well. Dr Moffic believes it is underappreciated in psychiatry and could be applied more. How can you apply it?

Psychiatric Aspects of Restorative Justice

, we worked with experts from multiple psychiatric areas to bring you thoughtful articles about a wide variety of psychiatric issues, from contingency management treatment for substance use disorders to burnout prevention tips for psychiatrists. Here are some highlights from the issue.

Imagine that you, as a physician, just saw this headline splashed all over the internet: “Depression Probably Not Caused by Excessive Black Bile.” It was followed by a long discourse on how an imbalance in the 4 bodily humors is not responsible for mood disorders. You might scratch your head and wonder why anyone in 2022 would be bothering to refute the Galenic-medieval humoral theory.

As senior academic psychiatrists and psychopharmacologists, we reacted with similar puzzlement to a recent umbrella review and follow-up article by researchers in the United Kingdom. The review, by Moncrieff et al and published in 

 (henceforth, “the review”), argued that there is “no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations” and that “the serotonin theory of depression is not empirically substantiated.” 

Contingency Management is a Powerful Clinical Tool for Treating Substance Use Research Evidence and New Practice Guidelines for Use

Contingency management (CM) is an effective behavior change technique commonly used to treat substance use disorders (SUDs). CM is one of the most effective behavioral interventions for initiating and maintaining abstinence from most types of commonly used drugs and alcohol.

CM-based treatments for SUD originate in basic behavioral science, namely the operant conditioning literature. Operant conditioning is a type of learning in which behavior is modified or maintained through the consequences it produces. In the context of SUD treatment, CM typically modifies substance use by delivering tangible, positive reinforcers (eg, prizes, vouchers, or monetary reinforcement) in exchange for evidence of the performance of the targeted behavior, such as the submission of a drug-negative urine sample. 

Just the Tip of the Iceberg: Psychiatric Implications of Overturning

The US Supreme Court defied the court’s tradition and the expressed intentions of some of its members during their confirmation hearings by overturning the 50-year-old precedent, 

, which had established abortion as a right. Immediately after the 

Dobbs v Jackson Women’s Health Organization

 decision was rendered on June 22, 2022, many states applied or enacted laws either severely limiting or banning abortion.

A week after the decision, a 10-year-old girl, pregnant by rape, was taken to Indiana, having been denied an abortion in her home state of Ohio. She was at high risk, not only for exacerbations of the trauma she had already experienced but for complications of pregnancy and childbirth, not to mention those of motherhood. It is notable, and relevant, that the first responses of Mike DeWine (Ohio’s governor), 

, and other media was to declare that the story was untrue or could not be confirmed. No apologies were offered when the rapist was arrested and confessed. Next, the physician who performed the abortion was accused of not recording the procedure as required by law. 

8 Tips for Psychiatrists to Prevent Burnout

In 2018, the American Psychiatric Association found that burnout among psychiatrists was nearly 50%. This number may be even higher as we persist through a global endemic disease, social and political unrest, and increasing economic stressors. In many states, the collateral impact on health care will only be exacerbated by the recent Supreme Court decision to reverse 

. This has led to increased burden on psychiatrists, our patients, and our colleagues in the medical field who turn to us for assistance.

 in itself can be polarizing and create stigma. It can place blame on the individual and does not take into account systemic or structural barriers that lead to untoward distress. At its core, burnout is an imbalance of empathy and self-compassion. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the September 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: September 2022

 (BD) as a condition that is characterized by recurrent and/or cyclical episodes of mania or hypomania and depression.

 In the DSM-5, there are 2 subtypes of BD: bipolar I disorder (BD-I) and bipolar II disorder (BD-II). A diagnosis of BD-I is established if an individual experiences at least 1 manic episode with additional major depressive and/or hypomanic episodes. Individuals are diagnosed with BD-II if they experience at least 1 hypomanic episode and at least 1 major depressive episode without any manic episodes. Although BD is not as common among older adults as it is among younger adults, available evidence indicates that the total number of 

 with BD is expected to increase significantly over the next few decades.

 It has been observed that between 1980 and 1998, the relative frequency of late-onset bipolar disorder increased from 1% to 11%.

According to the International Society for Bipolar Disorders (ISBD) Task Force, “older age bipolar disorder” (OABD) is defined as BD occurring in individuals ≥ 50 years of age.5One quarter of all cases of BD occur among individuals ≥ 60 years of age and > 10% of the cases occurred among individuals ≥ 70 years of age.

OABD has a point prevalence of 0.1% to 0.5% and a lifetime prevalence of 0.5% to 1.0%.

 Among older adults who are diagnosed with a 

 New-onset mania later in life occurs in approximately 10% of individuals with OABD, and it is often associated with neurovascular disease.

 Among older adults who go to the emergency room for a psychiatric evaluation, BD has been noted in 17% of cases.

 Approximately 8% to 10% of geriatric inpatient admissions and 6% of geriatric psychiatry outpatient visits include individuals with OABD. Among individuals who live in residential psychiatric program for older adults, the prevalence of bipolar disorder is approximately 17.4%.

 A diagnosis of BD is noted in approximately 3% of older nursing home residents and 9.7% of older chronically institutionalized individuals. Approximately 70% of individuals with OABD are women.

Comparison Between OABD and Early-Onset Bipolar Disorder

Individuals with OABD often present with depression rather than hypomania or mania as the presenting symptom.

 They also tend have more frequent recurrences of 

 and present with symptoms that are severe.

 In contrast to individuals with early-onset bipolar disorder (EOBD), individuals with OABD present with greater latency periods between the initial and subsequent mood episodes.

 There is also significantly less family history of mood disorders noted among individuals with OABD when compared to individuals with EOBD.

 These individuals also have a history of more stressful life events when compared to age-matched controls.

Individuals with OABD also present with more 

 including cardiovascular, respiratory, endocrine, and metabolic disorders.

 These individuals often present with an average of 3 to 4 comorbid medical conditions.

 These comorbid conditions also worsen outcomes for individuals with OAD, including the risk for suicide.

When compared to individuals with EOBD, individuals with OABD often present with greater association with cerebrovascular disease and other neurological disorders.

 They often present with increased white-matter hyperintensities in frontal, parietal, and putaminal brain areas.

 Individuals with OABD may have greater cortical sulcal widening and lateral ventricle-brain ratio scores when compared to individuals with EOBD.

 On neuroimaging studies, these individuals present with greater morphological abnormalities of the brain when compared to individuals with EOBD.

 It has also been noted that among individuals with OABD, depressive symptoms are often associated with left cerebral hemisphere vascular lesions, whereas manic symptoms are often associated with right cerebral hemisphere vascular changes.

Available evidence indicates that when compared to age-matched controls, psychiatric comorbidities are more common among individuals with OABD, but the rates of these comorbidities are lower than what is seen among individuals with EOAD.

 is the most common comorbid psychiatric disorder among individuals with OABD, with a 12-month and a lifetime prevalence of 38.1% and 38.1%, respectively.

 The other common psychiatric comorbidities are (12-month and lifetime prevalence rates): panic disorder (11.9% and 19.0%), 

 (9.5% and 20.5%), and dysthymia (7.1% and 15.5%). It has been noted that older women with OABD have a greater prevalence of panic disorder when compared to age-matched controls, whereas older men have a greater prevalence of alcoholism.

 Available evidence indicates that the prevalence rates for psychotic symptoms among individuals with OABD are similar to those of individuals with EOBD.

 When compared to individuals with EOBD, the risk for suicide among individuals with OABD appears to be lower.

When compared to age-matched controls, varying degrees of cognitive impairment have been identified among a majority of individuals with OABD.

 These include lower Mattis Dementia Rating Scale (DRS) scores (P=0.0003) and Mini-Mental State Examination (MMSE) scores (P=0.0007). When compared to individuals with EOBD, about half of individuals with OABD score ≥ 1 standard deviation (SD) below the mean on the DRS and MMSE total scores.

 However, no correlation has been noted between the Young Mania Rating Scale (YMRS) scores and the cognitive functioning among these individuals.

 Available evidence indicates that individuals with OABD also present with worse psychomotor functioning and mental flexibility when compared to individuals with EOBD.

 Greater cognitive impairment has been noted among individuals with OABD who have more vascular risk factors and a greater number of hospitalizations.

When compared to age-matched individuals with unipolar depression, individuals with OABD have an earlier age at onset of illness.

 They are also noted to have higher total symptom severity, to have higher positive symptom scores, and to be more impaired in community living skills.

 When compared to aged-matched controls, these individuals are also 4 times more likely to use mental health services and 4 times more likely to have psychiatric hospitalizations. The 

 describes the difference between EOBD and OABD.

It is imperative to obtain a detailed history when assessing individuals with OABD.

 This history will also help identify individuals who develop mood symptoms due to secondary medical and/or neurological disorders. Additionally, individuals who develop mood swings due to the effects of prescribed drugs or drugs of abuse can be identified by obtaining a thorough history. Comorbid medical and/or neurological disorders can be identified by a focused physical examination. Laboratory workup can also identify common conditions that cause mood symptoms, including hyperthyroidism.

 Laboratory workup that is commonly ordered as a screening tool among individuals with OABD include a complete blood count, a complete metabolic panel, a thyroid panel, urine-analysis and culture, and drug screen. Additional tests that can be ordered include vitamin B12 and folate levels, rapid plasma regain/Venereal Disease Research Laboratory test, and human immunodeficiency virus (HIV) testing if nutritional deficiency, neurosyphilis, or HIV infections are suspected as possible comorbid conditions. If cerebrovascular disease is suspected as a possible etiology for mood symptoms or there is evidence of cognitive dysfunction among individuals with OABD, computerized tomography or magnetic resonance imaging scans can be obtained.

Although there are no specific screening tools for the diagnosis of OABD, some available instruments can assist with quantifying and qualifying the symptoms of OABD and in monitoring their progress. The Mood Disorder Questionnaire is a common screening tool that has been identified as having good sensitivity and specificity for detecting a lifetime history of mania or hypomania, although the potential for over-diagnosis of BD is a known limitation for this screening instrument.

 Other screening instruments include the Bipolar Spectrum Diagnostic Scale, the Hypomanic Personality Scale, the Bipolar Depression Rating Scale, and the YMRS.

 The most widely used clinical assessment tool for the diagnosis of bipolar disorder is the structured clinical interview from the DSM-IV.

 After the screening process, the DSM-5 criteria can assist with confirming the diagnosis of BD.

 describes the process for diagnosing OABD.

Available evidence indicates that OABD is not an uncommon condition. Individuals with OABD present with less family history of psychiatric disorders but greater burden of medical comorbidities when compared to individuals with EOBD. When compared to age-matched controls, these individuals have higher rates of health care service utilization and worse outcomes. It is imperative to rule out underlying medical disorders, adverse effects of prescribed medications, and/or the adverse effects of drugs of abuse as possible etiologies for OABD.

is professor and chairman of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services in Omaha, Nebraska. He is also an adjunct professor of psychiatry at Yale School of Medicine.

is cofounder and managing principal of Behavioral Health Advisory Group in Princeton, New Jersey.

Desk Reference to the Diagnostic Criteria From DSM-5

. American Psychiatric Publishing; 2013:65-92.

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A report on older-age bipolar disorder from the International Society for Bipolar Disorders Task Force.

6. Sajatovic M, Blow FC, Ignacio RV, Kales HC. 

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Bipolar disorder in middle-aged and elderly adults: is age of onset important?

Prevalence of bipolar disorder in a psychogeriatric population.

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Mania compared with unipolar depression in old age.

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Depressive symptoms in early- and late-onset older bipolar patients compared with younger ones.

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Age of first onset of bipolar disorder: demographic, family history, and psychosocial correlates.

15. Beyer JL, Kuchibhatla M, Cassidy F, Krishnan KR. 

Stressful life events in older bipolar patients.

16. Gildengers AG, Whyte EM, Drayer RA, et al. 

Medical burden in late-life bipolar and major depressive disorders.

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Improving medical and psychiatric outcomes among individuals with bipolar disorder: a randomized controlled trial.

18. McIntyre RS, Konarski JZ, Soczynska JK, et al. 

Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization.

19. Juurlink DN, Herrmann N, Szalai JP, et al. 

Medical illness and the risk of suicide in the elderly.

Medical and psychiatric comorbidities among elderly individuals with bipolar disorder: a literature review.

The role of vascular risk factors in late onset bipolar disorder.

22. Lloyd AJ, Moore PB, Cousins DA, et al. 

White matter lesions in euthymic patients with bipolar disorder.

23. Tamashiro JH, Zung S, Zanetti MV, et al. 

Increased rates of white matter hyperintensities in late-onset bipolar disorder.

24. Sarnicola A, Kempton M, Germanà C, et al. 

No differential effect of age on brain matter volume and cognition in bipolar patients and healthy individuals.

25. Young RC, Nambudiri DE, Jain H, et al. 

Brain computed tomography in geriatric manic disorder.

Structural neuroimaging and mood disorders: recent findings, implications for classification, and future directions.

Current research in affective disorders following stroke.

28. Goldstein BI, Herrmann N, Shulman KI. 

Comorbidity in bipolar disorder among the elderly: results from an epidemiological community sample.

Cognitive impairment in bipolar disorder in old age: literature review and findings in manic patients.

Between 1980 and 1998, the relative frequency of late-onset bipolar disorder increased from 1% to 11%. How can you best assess for this condition? 