“Nursing home residents aren’t getting half of our resources or half of our attention, yet they account for roughly half the deaths.”

- David Grabowski, PhD, Harvard Medical School

Nursing homes and other long-term care settings provide an unfortunate perfect storm for pandemics. Most of the residents are old, ill, frail, often immunocompromised, and live in close quarters with roommates and others during congregate dining and activities.

 They are cared for by staff living in the community, many with young children, who then come into the facility and circulate among them every day, in addition to multiple family members who visit frequently. Combine this with unfortunate but inevitable slips in infection control, and a single infectious staff member or visitor can be like a spark to kindling. The rapid onset of the coronavirus disease 2019 (COVID-19) pandemic has highlighted all of these risk factors for infectious spread. There are hundreds of thousands of confirmed or suspected cases in United States nursing homes, and many deaths.

The COVID-19 pandemic has affected the mental health of residents in 2 fundamental ways; directly through infection, and indirectly, but more insidiously, through social isolation and other psychological stresses. In addition to its known pulmonary and other systemic effects, the coronavirus known as SARS-CoV-2 can infect the nervous system, with one pathway being directly through the olfactory bulb, and cause a variety of neurological and psychiatric symptoms in at least one-third to one-half of symptomatic individuals.

 Common acute neurological symptoms have been headache and loss of smell and taste, while more concerning symptoms include peripheral neuropathy, delirium, stroke, encephalitis, neurocognitive impairment, psychosis, and mood and anxiety disorders.

 These symptoms are seen acutely and can linger for weeks to months afterwards.

For any susceptible older individual in long-term care, key indicators of infection may include changes in energy, alertness, concentration, orientation, sleep, and appetite. COVID-19 testing is appropriate for any suspected situation with neuropsychiatric changes, regardless of whether there are respiratory symptoms or classic symptoms of fever and cough. Patients need early psychiatric consultation to ensure rapid identification and treatment of these symptoms, since acute changes can easily lead to long-lasting sequelae. Older individuals, especially those with frailty and dementia, need to be physically mobilized as soon as possible to reduce deconditioning, build confidence, and promote engagement with others.

The impact of stress and social isolation

For the past 7 months, long-term care residents have been confined to their rooms without congregate dining, activities, and in-person family visits. They lack exercise, direct sunlight and fresh air, and a normal level of social interaction. At times, residents have had limited access to medical, mental health, and other therapeutic services. Because the majority of residents are not tech-savvy or even tech-capable, they have been fully and passively reliant on the time and availability of staff to facilitate video chats with family and other loved ones.

The psychological stress of social isolation can be particularly jarring for these individuals, even those already acclimated to some degree of pre-existing social isolation. They spend most of their time alone in their rooms, without in-person contact with family and other loved ones. They are surrounded by staff members rendered less familiar due to masks, gowns, and face shields. Hearing and visual loss can make effective communication very difficult through multiple layers of personal protective equipment (PPE). Residents may be confused and frightened seeing everyone wearing PPE.

Patients may be traumatized by the news on radio or TV, seeing other residents ill or dying, being ill themselves, and by experiencing the disruptions and losses brought on by COVID-19 spreading throughout the facility. Even under the best of circumstances, residents are often bored, lonely, anxious, sad, and confused. Trying to communicate with them can be limited by generational differences across residents and younger staff and family members, further complicating their ability to understand and cope with what is happening.

 These emotional disruptions can lead to new or recurrent mental health conditions, post-traumatic symptoms, and even life-threatening states due to failure to thrive, especially in those who survived infection.

Is there a solution to these challenges, other than the end of the COVID-19 scourge? Rigorous infection control, including the screening and regular testing of all employees, along with proper and consistent use of PPE, can reduce the risk of residents being infected. Equally important are efforts to attend to the minds and souls of staff and residents with dedication and creativity. Here are several suggestions to help reduce social isolation and improve engagement with residents:

Staff have to become like surrogate family members with frequent and more lengthy contacts, and wear photos and name tags on top of their PPE

Regular video chats with family members facilitated by social work and/or therapeutic programming staff are essential

Regular telehealth visits should be provided by doctors and other therapists

Celebratory, fun, and interesting snacks, treats, and programming (eg, music therapy) can be brought to the door, room, and bedside

Drive-thru family visits to the facility can be set up, using masks and social distancing

Activities can be brought to rooms via video and/or closed-circuit TV

At the same time, the enormous stress on staff from actual and feared exposure at work, financial loss if they miss extended work time when quarantined or sick, and the physical burden of wearing restrictive and hot PPE all day must be recognized and addressed. During previous pandemics, front-line staff have faced an increased risk for anxiety, panic attacks, depression, acute stress reactions, PTSD, and even suicide. Several ways to build up the “emotional PPE” for staff and support them include:

Provide multi-lingual staff education on stress identification and reduction 

Focus on deep breathing, hydration, taking breaks, and sleep hygiene

Hold daily staff huddles with safe social gathering to provide updates, reassurance, inspiration, education, and opportunities to vent and ask questions

Have a confidential mental health hotline

Provide on-site counseling and referrals to Employee Assistance Programs (EAP) or other professional mental health services

We must remember that these frontline caregivers are true heroes, facing daily stress that can be overwhelming. There are effective ways to support them over time, augmented by calling upon the many individuals in the community who want to help. Find them and engage them!

is a geriatric psychiatrist and senior vice president for Behavioral Health and the chief medical officer for MIND Institute at Miami Jewish Health. His discussed these issues during his “The Top Dos and Don’ts in the Psychopharmacologic Treatment of Geriatric Patients: Focus on Dementia and Late-Life Depression and Anxiety” presentation at Virtual Psych Congress 2020.

1. Godfrey E. ‘We’re Literally Killing Elders Now’ - Thousands of Americans in long-term-care facilities have died from COVID-19. My grandmother just became one of them. 

. April 29, 2020. Accessed September 18, 2020. 

https://www.theatlantic.com/politics/archive/2020/04/coronavirus-especially-deadly-nursing-homes/610855/

2. Paulin E. How to Track COVID-19 Nursing Home Cases and Deaths in Your State. American Association of Retired Persons. Updated June 11, 2020. Accessed September 18, 2020. 

https://www.aarp.org/caregiving/health/info-2020/coronavirus-nursing-home-cases-deaths.html

3. COVID-19 Nursing Home Data. Centers for Medicare and Medicaid Services. Updated September 6, 2020. Accessed September 18, 2020. 

4. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. 

5. Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. 

6. Varatharaj A, Thomas N, Elllul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. 

7. Agronin M. Why It’s So Hard to Talk to Your Parents About the Coronavirus (and Vice Versa). 

https://www.wsj.com/articles/why-its-so-hard-to-talk-to-your-parents-about-the-coronavirus-and-vice-versa-11587236112

Articles

Psych Congress

The COVID-19 pandemic has affected the mental health of residents in 2 fundamental ways; directly through infection, and indirectly, but more insidiously, through social isolation and other psychological stresses.

The Impact of COVID-19 on Mental Health in Long-Term Care Settings

“Robert,” a 20-year-old male has struggled with worsening obsessions for the past 2 years. He obsesses about contamination and the possibility of spreading illness to others. In response, he performs multiple cleaning rituals throughout the day, often washing his hands for hours. These symptoms currently interfere with his ability to attend university classes, and he reports no quality of life as he cannot socialize with friends. Robert went to his primary care physician, who started him on fluoxetine 20mg/day. Within 2 weeks, Robert reported he was uncomfortably energized with the thought that he had superpowers. He was unable to sleep, began to spend money recklessly, and felt his mind was racing a mile per minute. This resulted in an emergency department visit where a psychiatrist made a diagnosis of bipolar disorder and discontinued the fluoxetine. Instead, he started him on valproic acid. Now, several weeks later, Robert denies any mood symptoms but continued to complain about his obsessive thoughts.

Obsessive–compulsive disorder (OCD) is characterized by obsessions or compulsions (or both) that are distressing, time-consuming, and oftentimes impairing. OCD has a lifetime prevalence of 1% to 3 % and thus ranks as one of the most common mental health illnesses.

 By contrast, the prevalence of current and lifetime comorbid OCD in bipolar disorder is estimated at 10.9% and 11.2% respectively. Conversely, bipolar disorder has been reported in approximately 10% to 20% of patients with OCD.

 This comorbidity is not only fairly common but also associated with greater psychosocial dysfunction and higher suicide attempts when compared with individuals with bipolar disorder without OCD

 and associated with more severe OCD symptoms than individuals with OCD without bipolar disorder.

Consistent with the case of Robert, research suggests that a majority of individuals with this comorbidity experience the onset of OCD prior to the onset of bipolar disorder

, with even some suggesting that OCD symptoms in childhood/adolescence may foreshadow a vulnerability to a later diagnosis of bipolar disorder.

After establishing the comorbidity, what should a clinician do in the case of a patient like Robert? Clearly, Robert’s bipolar disorder needs to be treated as untreated illness, or delayed treatment, may result in high rates of suicide, alcohol and drug problems, and psychosocial impairment.

 Similarly, if left untreated, OCD remission rates are low (approximately 20%) and suicide ideation and attempts are elevated.

 Fortunately, with appropriate treatment, patients report substantially higher rates of symptom response and remission and shorter durations of illness.

In general, the standard of care in terms of pharmacotherapy for OCD, and the medications FDA-approved for OCD, are the SSRIs and the SRI clomipramine, often used in high doses.

 This treatment approach, however, may have the unintended consequence of triggering a manic episode, as in Robert’s case. If antidepressants are used, clinical experience suggests that clinicians need to optimize prophylactic anti-manic agents before initiation. In Robert’s case, he was started on valproic acid. After mood stabilization, Robert’s clinician could then consider beginning OCD treatment with an SSRI, with careful monitoring of his mood.

Interestingly, some evidence suggests that in the case of comorbid bipolar disorder and OCD, that OCD symptoms may remit during effective treatment of the bipolar disorder. In fact, mood stabilizers alone or with atypical antipsychotics may be adequate to resolve comorbid symptoms of OCD and therefore SSRIs might not be necessary for many patients.

 Although the evidence is still preliminary, one could for example add aripiprazole (10 mg to 15 mg/d) to Robert’s antiepileptic (valproic acid) as both maintenance therapy for bipolar disorder and for treating his OCD symptoms.

Of course, if one is concerned about destabilizing Robert’s mood by adding medication to the antiepileptic he is taking, one could instead maximize exposure response prevent (ERP) therapy. Using ERP for OCD, 60% to 85% of patients report a considerable reduction in symptoms and improvement is often maintained for several years.

 ERP is usually delivered weekly or twice weekly, for approximately 20 to 30 total hours of therapy.

In summary, bipolar disorder frequently co-occurs with OCD and complicates the treatment of OCD. Having said that, if mood is stabilized before addressing the OCD, and the use of ERP is also entertained, people such as Robert can be hopeful of finding relief for both conditions.

Department of Psychiatry & Behavioral Neuroscience, University of Chicago. He spoke at PsychCongress in a presentation titled When Trouble Strikes Twice: Addressing the Complex Needs of Patients with Both OCD and Mood Disorders.

1. Grant JE. Clinical practice: Obsessive-compulsive disorder. 

2. Stein DJ, Costa DLC, Lochner C, Miguel EC, et al

3. Ferentinos P, Preti A, Veroniki AA, et al. Comorbidity of obsessive-compulsive disorder in bipolar spectrum disorders: Systematic review and meta-analysis of its prevalence. 

4. Amerio A, Odone A, Liapis CC, Ghaemi SN. Diagnostic validity of comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review. 

5. Ozdemiroglu F, Sevincok L, Sen G, Mersin S, et al. Comorbid obsessive-compulsive disorder with bipolar disorder: A distinct form? 

6. Tonna M, Amerio A, Odone A, Stubbs B, Ghaemi SN. Comorbid bipolar disorder and obsessive-compulsive disorder: Which came first? 

7. Tonna M, Amerio A, Odone A, Ossola P, Marchesi C, Ghaemi SN. Are obsessive-compulsive symptoms expression of vulnerability to bipolar disorder? 

8. Lublóy Á, Keresztúri JL, Németh A, Mihalicza P. Exploring factors of diagnostic delay for patients with bipolar disorder: a population-based cohort study. 

9. Albert U, De Ronchi D, Maina G, Pompili M. Suicide Risk in Obsessive-Compulsive Disorder and Exploration of Risk Factors: A Systematic Review. 

10. Marazziti D, Mucci F, Avella MT, Dell'Oste V, Baroni S, Dell'Osso L. Treatment of the obsessive-compulsive and bipolar disorders comorbidity: pharmacodynamic and pharmacokinetic evaluation. 

11. Amerio A, Maina G, Ghaemi SN. Updates in treating comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review. 

Bipolar disorder frequently co-occurs with OCD and complicates treatment of OCD symptoms. Special considerations are discussed.

OCD and Bipolar Disorder: Novel Insights

When working with older individuals with psychiatric symptoms, most clinicians are familiar with the adage “start low and go slow” to guide their prescribing. This refrain has often been augmented with the phrase “but do go” to emphasize the importance of not stopping too early in the titration process. What are the roots of this approach? And, how should it unfold when applied to 3 common psychiatric disorders seen in later life: neurocognitive disorders, depression, and anxiety?

The first principle of prescribing any medication in later life is to appreciate important changes in drug metabolism due to aging organ systems. In terms of pharmacokinetics (ie, what the body does to the drug), absorption time is generally stable since decreases in intestinal absorption are offset by increased transit time; distribution varies by type of drug since increased body fat and decreased body water lead to increased volume of distribution for lipophilic drugs and decreased for hydrophilic drugs; bioavailability is increased for many drugs since there is upwards of a 30% reduction in initial hepatic metabolism; and half-lives are often lengthened since renal excretion is slowed by up to 50%.1 In terms of pharmacodynamics (ie, what the drug does to the body), drug response is less predictable due to alterations in receptor sensitivity, neuronal loss, and changes in key cholinergic and serotonergic pathways. In addition, older individuals tend to be more sensitiveto drug effects and may require lower doses, especially with opioids, anesthetics, and benzodiazepines. Some of the most concerning side effects are due to anticholinergic, antihistaminic, extrapyramidal, and sedating properties of medications.

One major guideline for safe prescribing in later life is The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, also called the Beers List, which was first developed in 1991 by geriatrician Mark Beers, MD. The list highlights medications that pose undue risk for negative outcomes, including falls, injuries, and even death.2 Since 2011, the American Geriatric Society have been revising and updating the list based on both consensus and evidence-based approaches. With these considerations in mind, we can explore several psychiatric conditions frequently seen in older individuals who have multiple comorbid conditions and polypharmacy.

There are no cures nor disease-modifying treatments for Alzheimer disease, aside from several experimental agents. Instead, there are 2 categories of medications that are US Food and Drug Administration-approved to improve its symptoms. These include 3 acetylcholinesterase inhibitors (AChEIs) that are indicated for mild-to-severe Alzheimer such as donepezil, rivastigmine, and galantamine; and 1 NMDA (glutamate) receptor antagonist called memantine for moderate-to-severe Alzheimer. There is also evidence that these agents can improve symptoms in Lewy body dementia and vascular dementia.

Here are several key do’s and don’ts to keep in mind when prescribing these medications:

keep expectations modest; the goal is symptomatic improvement and not curing the disease.

promise disease slowing, but educate patients and caregivers about realistic expectations and side effects.

start with the lowest dose and titrate slowly, per guidelines.

combine multiple acetylcholinesterase inhibitors.

combine acetylcholinesterase inhibitors with memantine as the disease progresses into moderate and advanced stages.

monitor closely for important side effects of AChEIs such as nausea, vomiting, diarrhea, nightmares, or slowed heart rate; and sedation, dizziness or confusion with memantine use.

start early. The later in the disease course you initiate use of cognitive enhancers, the less benefit you may see. Remember that studies have shown significant symptomatic benefit even in moderate-to-severe disease states.

Treating older individuals with depression poses unique challenges and considerations. Various forms of late-life depression affect 9% to 18% of individuals older than 55, and these rates increase significantly after the age of 85, especially for individuals in nursing homes and hospitals. On the other hand, the more serious and specific diagnosis of major depressive disorder is less prevalent than in younger individuals, with rates of 2% versus 6% to 7%.

Depression can have significant impacts on our bodies by accelerating brain aging and increasing the risk for medical conditions such as diabetes mellitus, cancer, neurocognitive disorders, and both cardiovascular and cerebrovascular disease and events. Risk factors associated with late-life depression include female gender, chronic medical illness, neurocognitive impairment, functional impairment, social isolation, and major life stresses. In many older individuals, depression may present with less mood-related symptoms and more physical or functional complaints and social issues, including fatigue, weight loss, pain, social isolation, resistance, agitation, self-neglect, and substance use. Up to 30% of older individuals with depression may have impairment in executive dysfunction, often due to vascular damage to frontolimbic white matter tracts. This “depression executive dysfunction syndrome,”as described by George S. Alexopoulos, MD, is notable for a poorer response to antidepressants and cognitive-behavioral therapy, earlier relapse, and a greater risk for recurrence.

In terms of selecting an antidepressant for older individuals, there is no favored agent based on multiple studies and meta-analyses, but they all work better than placebo.

 In general, individuals older than 55 years have slightly lower response rates and higher relapse rates compared to younger individuals.

Augmentation strategies that have shown efficacy for late-life depression include the use of antipsychotics, lithium, and methylphenidate. The addition of acetylcholinesterase inhibitors may help improve cognitive deficits, but they have not been shown to be helpful for depressive symptoms. Although antidepressants can improve depression and quality of life associated with medical illnesses, they do not clearly improve the medical conditions themselves. The exception of this is post-myocardial infarct depression, for which they may reduce the risk of recurrent cardiac events, procedures, and overall mortality.

Anxiety disorders are very common conditions in late life, affecting 1.2% to 28% of older patients depending on the subtype of disorder; generalized anxiety disorder and phobias are the most common. Higher rates are seen in chronic obstructive pulmonary disease, diabetes, depression, Alzheimer disease, and Parkinson disease. Antidepressants are first-line treatments, with both selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors most commonly used.

Benzodiazepine use in older patients is often necessary but must be managed carefully. On the one hand, they work quickly and effectively, and at low doses there is little risk of dose escalation or addiction. In general, there is a low risk of drug-drug interactions except with alcohol or other sedative-hypnotics. The purported risk of dementia associated with benzodiazepine use has limited evidence; even if true, it is less of a priority when working with older adults suffering from acute anxiety, especially when they may already have neurocognitive impairment.

 There is good reason for caution, however, given their concerning risk-to-benefit ratio, especially when prescribed by non-specialists. In older patients, benzodiazepine use is associated with an increased risk of falls with fractures, excess sedation, cognitive deficits, and motor vehicle accidents, and an overall elevated mortality rate.

Here are several important suggestions for safer benzodiazepine use:

use in individuals who have a history of unsteady gait, falls, or who are already on multiple medications affecting the central nervous system.

combine with other benzodiazepines or sedative-hypnotics.

 use when there is active alcohol or other substance abuse.

long-term use, escalate doses unnecessarily, or abruptly withdraw the medication.

use antidepressants as the pharmacologic base for anxiety disorders, with benzodiazepines as short-term options for severe symptoms.

use cognitive behavioral therapy, sleep hygiene, and other forms of psychotherapy.

remember that lorazepam and temazepam have no active metabolites since they are metabolized by conjugation only.

Benzodiazepines can be helpful in the short run for acute anxiety and panic while waiting for the more enduring antidepressant to take effect. Thereafter, they are best used only on an as-needed basis and always with close supervision. Individuals with Alzheimer disease and other neurocognitive disorders will be especially vulnerable to side effects of confusion and sedation. In some circumstances, low dose antipsychotics and trazodone can substitute for benzodiazepines, but only under the careful management of a geriatric psychiatrist or other specialist.

1. Shi S, Klotz U. Age-related changes in pharmacokinetics. 

2. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. 

3. Kok RM, Reynolds CF. Management of depression in older adults: a review. 

4. Alexopoulos GS. Mechanisms and treatment of late-life depression. 

5. Cipriani A, Furukawa TA, Salantiet G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. 

6. Tedeschini E, Levkovitz Y, Lovieno N, et al. Efficacy of antidepressants for late-life depression: a meta-analysis and meta-regression of placebo-controlled randomized trials. 

7. Kim JM, Stewart R, Yong-Seong L, et al. Effect of escitalopram vs placebo treatment for depression on long-term cardiac outcomes in patients with acute coronary syndrome: a randomized clinical trial. 

8. Crocco EA, Jaramillo S, Cruz-Ortiz C, Camfield K. Pharmacological management of anxiety disorders in the elderly. 

9. Salzman C, Shader RI. Benzodiazepine use and risk for Alzheimer disease.

10. Markota M, Rummans TA, Bostwick JM, Lapid MI. Benzodiazepine use in older adults: dangers, management, and alternative therapies. 

When working with older individuals with psychiatric symptoms, most clinicians are familiar with the adage “start low and go slow.” But what other tips should you consider when prescribing psychopharmacology? 

Do’s and Don’ts of Psychopharmacology in Late Life: Key Challenges and Opportunities

“Impulsivity” and “compulsivity” are 2 constructs that typify a range of disorder presentation. Impulsivity encompasses a predisposition toward poorly conceived actions, taking undue risks, and a lack of consideration when making decisions. Compulsivity is thought of as an inappropriate and maladaptive persistence of repetitive behavior, undertaken according to rigid rules and/or as a means of avoiding perceived negative consequences. However, when we examine co-occurrence of mental health disorders, we often see impulsive and compulsive disorders within the same individuals.

For example, rates of substance use disorders (typically considered impulsive behaviors) are considerably higher in people with body dysmorphic disorder (ie, a prototypical compulsive disorder) than in the population at large (49% compared with 29%). Conversely, rates of OCD (a compulsive disorder) are elevated relative to the general population in people with bipolar disorder (a disorder characterized often by impulsivity) (11% compared with 2%).

Impulsive and compulsive problems are often examined separately as disparate constructs, but the co-occurrence and fluidity by which the two constructs may transition from one to the other suggest that some shared variance, and common brain mechanisms, may contribute to both. Thus, while impulsive and compulsive behaviors may exist in isolation, it also may not be uncommon for an individual to struggle with both drives simultaneously.

Features of impulsive and compulsive behavior when they co-occur may reflect a lack of control over thoughts and behavior and may suggest a trans-diagnostic ‘disinhibition’ phenotype.If true neurobiologically, then we need to think about treatment approaches to these co-occurring but perhaps atypically pared features and the treatments may need to target some shared underlying construct such as disinhibition.

is professor, Department of Psychiatry & Behavioral Neuroscience, University of Chicago. He spoke at PsychCongress in a presentation titled "When Trouble Strikes Twice: Addressing the Complex Needs of Patients with Both OCD and Mood Disorders."

. 2014;371(7):646-653. doi:10.1056/NEJMcp1402176

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Impulsive and compulsive behaviors intersect and commonly occur within the same individuals.

Addressing the Impulsive Side of Compulsivity (And Vice Versa)

The COVID-19 pandemic has hit particularly hard on older individuals, who are more susceptible to serious illness as a result of underlying comorbid conditions. We see a similar phenomenon in many natural disasters, in which age is often a liability in terms of physical injury and death. Not surprising, we end up defining aging in terms of decline, disease and death, and viewing older individuals solely as potential victims. This attitude limits the way in which we can communicate with and learn from the elders in our lives—and it leads us, in turn, to denigrate our own aging selves.

Here is a counterpoint to this approach: aging brings key strengths that enable us to make better decisions, cope better, and even thrive during adversity: 

1. Wisdom
2. Resilience
3. Purpose
4. Creativity

Wisdom is one key strength, based upon not only all of the skills, experiences and knowledge that we accumulate with age, but also on ways in which our brains and minds draw upon and integrate different parts and perspectives better.

Research tells us that aging minds are more positive, practical and less emotionally reactive and impulsive. This wisdom make us more psychologically resilient as we age, enabling us to cope better with adversity. We can couple these strengths with a sense of purpose that often grows and deepens with age, conferring all sorts of benefits including improved wellness, fewer cardiovascular events, and even longer lives.

Another emergent strength is creativity, enabling us to express ourselves through art, relationships, volunteer work and other endeavors that can transcend the many physical and cognitive changes that may otherwise bog us down with age. Put together, the clear lesson here is to learn from and be inspired and guided by both aging and the elders around us. We need to celebrate the strengths that only aging can confer.

We need to celebrate the strengths that only aging can confer.

4 Components of Positive Aging

Bipolar disorder is a serious illness resulting in significant psychosocial morbidity and excess mortality. Through the years a number of research reports, reviews, and commentaries have suggested that bipolar disorder is underrecognized, and that many patients, particularly those with 

 Even for those patients in whom bipolar disorder is eventually diagnosed, the lag between initial treatment seeking and the correct diagnosis is often more than 10 years.

 The treatment and clinical implications of the failure to recognize bipolar disorder in depressed patients include the underprescription of mood stabilizing medications, an increased risk of rapid cycling, and increased costs of care.

 Recommendations for improving the detection of bipolar disorder include careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires.

Although the research is less robust, some studies have also found that bipolar disorder is sometimes overdiagnosed. 

 evaluated 21 patients with a substance use disorder who were admitted for residential treatment and had been previously diagnosed with bipolar disorder. Only 9 (42.9%) were diagnosed with bipolar disorder when administered a semi-structured interview. The other 12 patients were diagnosed with a substance-induced mood disorder. 

 evaluated 85 patients admitted to an inpatient dual diagnosis unit specializing in the treatment of mood and substance use disorders who had been diagnosed with bipolar disorder by their outpatient psychiatrist. Similar to the results of Stewart and El-Mallakh, only a minority of the patients (32.9%) had the diagnosis of bipolar disorder confirmed.

As part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, our clinical-research group conducted the largest study of bipolar disorder underdiagnosis and overdiagnosis.

 We used the Structured Clinical Interview for DSM-IV (SCID) to interview 700 psychiatric outpatients presenting for treatment. Before the interview, the patients completed a self-administered questionnaire which asked them whether they had been previously diagnosed by a health care professional with bipolar or manic-depressive disorder. Family history information was obtained from the patients regarding their first-degree relatives. Slightly more than 20% of the sample reported that they had been previously diagnosed as having bipolar disorder (n = 145, 20.7%), significantly higher than the 12.9% rate based on the SCID. More than half (56.6%, n = 82) of 145 patients who reported that they had a previous diagnosis of bipolar disorder did not have a diagnosis of bipolar disorder based on the SCID. Bipolar disorder was also underdiagnosed in some patients, but three times as many patients had been overdiagnosed as had been underdiagnosed (82 

Patients with SCID diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder in their first-degree relatives than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID. A family history of bipolar disorder was similar in patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID and patients who were negative for bipolar disorder by self-report and the SCID. Thus, the results of the study suggested that bipolar disorder was sometimes underdiagnosed, more often overdiagnosed, and the family history analyses supported the validity of the diagnostic procedures.

In a follow-up to this initial study we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis.

 We compared the diagnostic characteristics of 2 groups of patients who were not diagnosed with bipolar disorder based on the SCID interview—those who reported previously being diagnosed with bipolar disorder (n = 82) and those had not been so diagnosed in the past (n = 528). We conducted a logistic regression analysis to examine which diagnoses were independently associated with bipolar disorder overdiagnosis and found that borderline personality disorder, posttraumatic stress disorder and any impulse control disorder were independently associated with bipolar disorder overdiagnosis. Nearly 40% (20/52) of the patients diagnosed with DSM-IV borderline personality disorder had been overdiagnosed with bipolar disorder.

Thus, under- and overdiagnosis of bipolar disorder is possible. Recommendations for addressing the underdiagnosis problem include careful clinical evaluations inquiring about a history of mania and hypomania (which might include an interview with informants) and the use of screening questionnaires.

 Several scales have been developed to screen for bipolar disorder.

Administration of a screening scale is the first stage of a 2-stage diagnostic process. The more expensive and extensive second stage is only conducted when the patient screens positive. Consequently, it is important for a screening scale to have high sensitivity. Clinicians who rely on the screening scale as the first stage of a 2-stage diagnostic assessment, with the second stage being the more in-depth diagnostic interview, will miss the diagnosis in patients who are false negatives on the screening instrument.

 of studies of the Mood Disorders Questionnaire (MDQ), the most frequently studied screening scale for bipolar disorder, found that the MDQ’s sensitivity was 62% based on the recommended cutoff of 7.

 Thus, more than one-third of true cases of bipolar disorder would be missed if the MDQ was relied upon as the first stage of a 2-stage diagnostic process. In general psychiatric outpatient practices, the positive predictive value of the MDQ (ie, the likelihood of a patient who screens positive having bipolar disorder) is less than 50%.

Putting aside the performance statistics of bipolar disorder screening scales, the use of these scales can be questioned at a conceptual level. The reason for suggesting the use of these scales is that bipolar disorder is underdiagnosed. But the advocates for the use of screening questionnaires do not indicate how and why a paper-and-pencil questionnaire is expected to help improve diagnostic recognition? Are mental health clinicians often failing to inquire about a history of mania/hypomania in depressed patients, and will only do so when a screening scale is first completed? Do mental health clinicians not know what questions to ask to assess prior manic/hypomanic episodes and therefore these scales are needed because the scales ask the right questions that clinicians do not ask? Do mental health clinicians know what questions to ask, but ignore or discount positive responses from patients and this is the cause of bipolar disorder underdiagnosis?

That is, do the advocates of bipolar disorder screening scales believe that self-report screening questionnaires will improve bipolar disorder recognition because the results of these tests are less easily ignored than the responses of a patient to a clinical interview? Researchers of the performance of bipolar disorder screening scales have not addressed these questions in the Discussion sections of their papers.

I would argue that bipolar disorder screening questionnaires are superfluous. Because bipolar disorder screening scales have modest sensitivity, a clinical interview is necessary to reduce false negatives. Because bipolar disorder screening scales have modest positive predictive value, a clinical interview is necessary to reduce false positives. Thus, a clinical evaluation is always needed regardless of the results of the screening test. Consequently, it is not clear how a screening scale for bipolar disorder would be helpful in a psychiatric setting. The advocates of bipolar disorder screening, who suggest that such scales be routinely used in clinical practice, should indicate how these measures should interface with a clinician’s evaluation. By my reckoning a clinical evaluation is needed regardless of the results of the screening scale; thus, it is unclear what niche these measures should occupy.

is Professor of Psychiatry and Human Behavior, Brown University; Director of Outpatient Psychiatry and Partial Hospital Program, Rhode Island Hospital, Brown Medical School. He spoke at Psych Congress in a presentation titled “Does My Patient Have Bipolar Disorder? A Review of Diagnostic Concerns, Conundrums, and Confusion and What to Do About It.” The author reports no conflicts of interest concerning the subject matter of this article.

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2. Katzow JJ, Hsu DJ, Ghaemi SN. The bipolar spectrum: a clinical perspective. 

3. Manning JS, Haykal RF, Connor PD, Akiskal HS. 

On the nature of depressive and anxious states in a family practice setting: the high prevalence of bipolar II and related disorders in a cohort followed longitudinally

1997;38:102-8. doi: 10.1016/s0010-440x(97)90089-4.

4. Ghaemi SN, Boiman EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. 

5. Ghaemi SN, Ko JY, Goodwin FK. "Cade's disease" and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. 

6. Hirschfeld RM. Bipolar spectrum disorder: improving its recognition and diagnosis. 

7. Hirschfeld RM, Vornik LA. Recognition and diagnosis of bipolar disorder. 

8. Yatham LN. Diagnosis and management of patients with bipolar II disorder. 

9. Hantouche EG, Akiskal HS, Lancrenon S, et al. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). 

10. Perugi G, Akiskal HS, Lattanzi L, et al. The high prevalence of "soft" bipolar (II) features in atypical depression. 

11. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 survey of individuals with bipolar disorder. 

12. Lish J, Dime-Meenan S, Whybrow P, et al.The National Depressive and Manic-depression Association (DMDA) survey of bipolar members. 

13. Birnbaum HG, Shi L, Dial E, Oster EF, Greenberg PE, Mallett DA. Economic consequences of not recognizing bipolar disorder patients: a cross-sectional descriptive analysis. 

14. Shi L, Thiebaud P, McCombs JS. The impact of unrecognized bipolar disorders for patients treated for depression with antidepressants in the fee-for-services California Medicaid (Medi-Cal) program. 

15. Matza LS, Rajagopalan KS, Thompson CL, de Lissovoy G. Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs. 

16. Isometsa E, Suominen K, Mantere O, et al. The Mood Disorder Questionniare improves recognition of bipolar disorder in psychiatric care. 

Is bipolar disorder overdiagnosed among patients with substance abuse?

18. Goldberg J, Garno J, Callahan A, et al. 

Overdiagnosis of bipolar disorder among substance use disorder inpatients with mood instability

19. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? 

20. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Psychiatric diagnoses in patients previoulsy overdiagnosed with bipolar disorder. 

21. Angst J, Adolfsson R, Benazzi F, et al. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. 

22. Hirschfeld R, Williams J, Spitzer R, et al. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. 

23. Parker G, Fletcher K, Barrett M, et al. Screening for bipolar disorder: the utility and comparative properties of the MSS and MDQ measures. 

24. Ghaemi SN, Miller CJ, Berv DA, Klugman J, Rosenquist KJ, Pies RW. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. 

25. Wang HR, Woo YS, Ahn HS, Ahn IM, Kim HJ, Bahk WM. 

The validity of the Mood Disorder Questionnaire for screening bipolar disorder: A Meta-Analysis

26. Zimmerman M, Galione J. Screening for bipolar disorder with the Mood Disorders Questionnaire: A review. 

Overdiagnosis of bipolar disorder is as important to guard against as its underdiagnosis. The use of bipolar disorder screening tools is questioned.

Diagnosing Bipolar Disorder in Clinical Practice: Underdiagnosis, Overdiagnosis, and Screening 

Last month, I was contacted by a psychiatrist seeking to consult my expertise in transgender care for a clinical dilemma. A patient of hers needed a second letter for surgery from a psychiatrist in order for the surgery to be covered by insurance. The patient’s therapist had already written a letter supporting surgery. The psychiatrist was aware that the World Professional Association for Transgender Health Standards of Care 7 (

) criteria for surgery was that mental illness was “well-controlled.”

 The patient had missed appointments with the psychiatrist for treatment of a mood disorder with substance use. However, the psychiatrist felt the patient would benefit from surgery. Could she write the letter?

As a co-author of WPATH SOC 7, I had heard variations on this question many times. And as chapter lead of the mental health chapter in the upcoming WPATH SOC 8, I have been working to try to provide more clear guidance to psychiatrists and other mental health professionals on the care of transgender people who also have mental illness and substance use disorders.

Since 1979, WPATH has periodically revised its Standards of Care, which choreograph the multidisciplinary care of transgender (or trans) people who are transitioning.

 Mental health professionals or primary care providers can assess patients for starting hormones. One or 2 evaluations from mental health professionals are recommended before surgery. Criteria for surgery include capacity for informed consent, persistent gender dysphoria, and that mental illness, if present, is “well-controlled.” There is a recommendation that patients live in the gender role in which they intend to live, and be on a stable hormone regimen, if indicated, for a year before genital reconstruction surgery.

From 1981 to 2014, the US Department of Health and Human Services banned reimbursement under Medicare for trans care. Coverage was excluded under Medicaid programs and most private insurance as well. The lack of insurance coverage meant that many trans people lacked access to care, and little trans care was provided by most health systems. Research was not funded in the United States.

 Physicians did not receive much training in trans care in medical schools, because academic health centers provided little care. All of this has changed dramatically in the last decade, and with increasing patient visits, training health providers in care for trans people has new urgency.

 Many states now require state-regulated private insurance and Medicaid coverage for transgender care, including surgery. Medicare has removed its ban on trans care coverage, though approval of surgical procedures are on a case-by-case basis. The Obama administration attempted to remove trans health exclusions in all states under Rule 1557 of the Affordable Care Act, though these efforts have been hampered by the current administration and a federal judge’s ruling. Removal of remaining trans health insurance exclusions awaits future court decisions or perhaps the next administration. But there has been a national sea change in insurance coverage since 2013.

Because of these funding restrictions, there was little research on trans-care and mental health in the United States until the past decade, but there has been data from European studies on mental health in trans people. Swedish lifetime longitudinal data showed that trans people there who had transitioned with social transition, hormones, and surgery still had increased mental health morbidity and mortality compared to the general population.

 However, the regret rate for transition in Sweden from 1960-2010 was very 

 A recent analysis of the Swedish data on initial publication showed a 

 in mental health utilization in those who had surgery versus those who had not

; however, the paper’s statistical analysis has been 

 of 72 studies from 1991 to 2017, that transition reduces gender dysphoria, improves quality of life, and that regret rates for transition are low.

The World Professional Association for Transgender Health is now working on the Standards of Care Version 8, due to be released in 2021. WPATH SOC 8 is a far larger effort than previous Standards of Care, with many experts in transgender health from around the world participating. Of note, a far larger share of the experts are health professionals who are themselves trans.

Experts in transgender health from around the world are participating in and making more sweeping efforts to streamline mental health care for all sectors of the population.

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