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The Depression Boom: As US Population Ages, Mental Illness Rises
One Doctor’s Focus to Treat Older Adults
By Courtney Reyers, NAMI Director of Publishing
With Baby Boomers reaching late adulthood, the chance for developing depression, anxiety and other mental illnesses could rise. Depression affects more than 6.5 million of the 35 million Americans aged 65 years or older. One psychiatrist in particular, Dr. Dilip Jeste, addresses the needs of older populations when it comes to mental illness. He specializes in late-onset schizophrenia, depression in older populations and psychosis. Currently, he is the Distinguished Professor of Psychiatry and Neurosciences, Estelle and Edgar Levi Chair in Aging, and Director of the Sam and Rose Stein Institute for Research on Aging, at the University of California, San Diego School of Medicine. He is also the president of the American Psychiatric Association. Dr. Jeste is the first Asian American to ever be elected president of the APA, and is the first psychiatrist from India to be elected to the Institute of Medicine at the National Academy of Sciences. He is a renowned lecturer and accomplished author. NAMI was fortunate enough to recently speak with Dr. Jeste about his work. If you’d like to hear Dr. Jeste speak, plan on attending NAMI’s National Convention in June.
NAMI: You focus on geriatric psychiatry. Can you speak to the difference in mental illness in older populations vs. the general population?
Jeste: Over the next 25 years, with the aging of the baby boomers, we will witness the largest increase in the numbers of people over age 65 in the history of mankind. What is less well-known is the fact that the numbers of older people with mental illness will actually increase at a disproportionately faster rate than those in the general population. This will be, in part, because of higher incidence of depression, anxiety disorders and substance use disorders among people born after the World War II than in those born earlier. Other reasons include decreasing social stigma, resulting in a larger proportion of older people being diagnosed with and treated for mental illness and an increase in the average life span of people with serious mental illness, which is currently 20 years shorter than that in the general population.
Just as children are not small adults, elderly people are not merely older adults. They have unique health care needs. The most common neuropsychiatric disorder in older people is dementia, especially Alzheimer’s disease. While major depression is less common, milder forms of depression are far more common than in younger adults. Also, because of age-related changes in the functioning of liver, kidneys and brain, older people can only tolerate lower doses of most medications and are at a greater risk of developing a number of side effects. They also have special needs for psychosocial treatments (e.g., they are less likely to be living with their families). Additionally, they tend to have major physical illnesses and disabilities, have visual and hearing impairments, and have even less access to health care than younger adults. As a result, fewer than half of older Americans with mental illness receive the needed mental health services. They face the dual stigma of mental illness and aging. Finally, there is a severe shortage of workforce trained to provide the necessary mental and physical health care for the growing numbers of older adults.
Can you tell us your thoughts on “wisdom?” What does it mean to you, and how would you define it?
Jeste: I have developed increasing interest in the area of successful aging: what makes older people do well, feel happy and contribute to society at a high level. This led me to do research on wisdom and to study whether wisdom increases with aging. Wisdom, a unique attribute rich in history dating back to the dawn of civilization, is a newcomer to the world of empirical research. For centuries, wisdom was the sole province of religion and philosophy, but I believe it is a real entity with biological roots.
Defining wisdom is rather subjective, though there are many similarities in definitions across time and cultures. Components of wisdom that are commonly agreed on include: thoughtful decision-making, empathy, compassion or altruism, emotional stability, self-understanding, decisiveness and tolerance for divergent values.
Research suggests that there may be a neurobiological basis for wisdom's components. Several specific brain regions appear to be involved in different components of wisdom. Neurobiology of wisdom probably involves an optimal balance between more primitive brain regions (the limbic system) and the newest ones (pre-frontal cortex.)
Understanding the neurobiology of wisdom may have considerable clinical significance, for example, in studying and eventually treating disorders such as antisocial personality disorder and certain types of dementia such as the fronto-temporal dementia. In addition, age-associated wisdom may help to overcome the negative effects of diseases and stressors that are common in late life and lead to improved mental health and psychosocial functioning.
What are some challenges you see in your work in terms of older populations and mental illness?
Jeste: The existing infrastructure and financing of health care, pool of mental health care providers with adequate geriatric training and mental health care delivery systems are extremely inadequate to meet the challenges posed by the expected increase in the numbers of older adults with mental illness. A national crisis in geriatric mental health care is emerging. Today there are only about 1,800 board-certified geriatric psychiatrists in the U.S.—one for every 23,000 older Americans. That ratio is estimated to diminish to one geriatric psychiatrist for every 27,000 individuals 65 and older by 2030. Yet, little is being done to address this challenge. Deliberate and coordinated action is urgently warranted.
A basic problem is pervasive ageism. The aging of the population is often dubbed as the “silver tsunami.” Older people are seen as a burden on the society, especially in terms of rising costs of Social Security and Medicare. Yet our study suggests that there is a growing number of old adults who can be productive and contribute to the society in many ways. Successfully aging seniors can, in fact, be a great resource for younger generations. I consider this “the positive psychiatry of aging,” which will be the future of our field.
Reduction of the rising costs of health care is also possible, and prevention is the way to do so. Research has shown that depression raises the cost of medical care in older adults significantly; yet, it is usually treatable and sometimes preventable. For example, focus on methods for early detection and treatment or even prevention of a depressive episode that commonly follows heart attack or stroke.
Late-onset schizophrenia is not something we read about often. The perception is that schizophrenia hits in the late teens or 20s. Can you talk more about that?
Jeste: Schizophrenia is usually thought to have its onset in early life—usually in the teens or 20s. However, we and several other research groups have found that approximately 20 percent of people with schizophrenia first manifest their illness after the age of 40. The symptoms, course and treatment response in this late-onset schizophrenia are largely similar to those in earlier-onset schizophrenia. However, there also are some differences. For example, late-onset schizophrenia is usually of paranoid type and is much more common among women (mostly post-menopausal) than in men—just opposite of earlier-onset schizophrenia. There is also a greater prevalence of hearing loss and vision problems in late-onset schizophrenia; on the other hand, late-onset schizophrenia tends to have better prognosis and the treatment involves lower daily dosages of antipsychotics than those necessary to treat earlier-onset schizophrenia.
You co-authored a book on Tardive Dyskinesia. Are there truly any treatments for this side effect?
Jeste: Neuroleptic-induced tardive dyskinesia is one of the most serious adverse effects of prolonged use of typical or conventional antipsychotics such as haloperidol and fluphenazine. Despite the efforts of researchers, as yet there appear to be no consistently reliable therapy for this syndrome, which is potentially persistent and sometimes irreversible. A number of treatments such as vitamin E have been reported to work in some patients, but the best treatment is discontinuation of the typical antipsychotics, when it is feasible. Fortunately, the newer atypical antipsychotics are much less likely to cause TD than the older typical antipsychotics. Of course, long-term use of atypical antipsychotics is associated with a different set of side effects such as weight gain and diabetes.
What are your plans for your future work?
Jeste: As mentioned above, in recent years, I have been studying successful aging and wisdom in the population at large. My plan is to expand this work to people with serious mental illness. Little is known about the rate of successful aging in persons with severe illnesses. We have recently begun separate research studies on successful aging in people with schizophrenia and those infected with HIV. Our hope is that understanding factors that promote successful aging at an individual level would lead to the development of new preventive and therapeutic interventions aimed at improving quality of life and well-being in older adults living with chronic illness.
I would like to focus on reducing the social stigma associated with old age as well as mental illness. This can be done, in part, by showing positive outcomes of both (i.e., successful aging in people with mental illness). I believe that adequate attention has not been paid to positive psychological factors such as resilience, optimism, social engagement and wisdom. I would like to develop interventions to enhance these positive traits in people with mental illness with the goal of hastening and sustaining their recovery. This is what I call Positive Psychiatry.
I also look forward to continuing my work with NAMI, the largest and most influential mental health advocacy group in the U.S. as well as the world. I have had the pleasure and privilege of collaborating with NAMI both at national and local levels over a long time. I hope to increase that partnership in the years to come.
Dr. Jeste earned his medical degree in Pune, India, and trained in psychiatry in Mumbai, India. After coming to the U.S., he completed his psychiatry residency at Cornell University and his neurology residency at George Washington University. He was a research fellow as well as Chief of the Units on Movement Disorders and Dementias at the National Institute of Mental Health (NIMH). After joining the UC San Diego School of Medicine, Dr. Jeste developed an NIMH-funded Geriatric Psychiatry Clinical Research Center. He serves as editor-in-chief at the American Journal of Geriatric Psychiatry. To learn more on wisdom, read Dr. Jeste’s article in the Journal of the American Medical Association. Dr. Jeste will speak at the 2013 NAMI National Convention in San Antonio during the Research Plenary on Sunday, June 30.