Or

Colin Depp, Ph.D., Associate ProfessorUCSD Dept. of Psychiatry

Successful Aging and Bipolar Disorder

Overview• Brief broad background on population aging

• Aging and bipolar disorder

• Interventions for older adults with bipolar disorder

• Applying healthy aging concepts to bipolar disorder

• Summary and discussion

1900

(in millions)

MALES FEMALES

21st Century

70-74

65-69

60-64

55-59

50-54

80+

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

75-79

AGE PYRAMID IN USA (Olshansky, 1997)

75-79

70-74

65-69

60-64

55-59

50-54

80+

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

Age Pyramids in Japan

Rapid Changes in Health of Older People: The Civil War Studies

Fogel et al., 1998

Characteristics of the Civil War

Cohort• 25% died in infancy

• 40% died before age 15

• Leading causes of death were infectious

disease

• Food clothing and shelter accounted for

75% of costs (now 13%)

• 3100 hours of work per year and two

hours per day of leisure (now 50%)

Absence

of

disease/

disability

Engagement

with life

High

cognitive and

physical

function

(Rowe and Kahn, 1998)

Components of Successful Aging

SUCCESSFUL

AGING

Overview• Brief broad background on population aging

• Aging and bipolar disorder

• Interventions for older adults with bipolar disorder

• Applying healthy aging concepts to bipolar disorder

• Summary and discussion

“You know you are manic when you see that the sink is leaking, and you start to fix it, and the next thing you know, three hours have passed and there is a hole in the wall and water is everywhere and then you realize…it’s not your house”

- 62 year old man with BD

Estimated Number of People with Major

Psychiatric Disorders by Age Group

7

8

9

10

11

12

13

14

15

16

2000 2010 2020 2030

Mil

lion

s

18-29 30-44 45-64 65 >

Jeste, Alexopoulus, Bartels, et al., 1999

Years of Life Lost in Mental Illness

Diagnosis Mean Years of Life Lost

Schizophrenia 12.2

Bipolar Disorder 10.4

Substance Abuse 14.2

Depression 8.9

Chang et al., PLOS ONE 2011

Common Medical Conditions in Patients Diagnosed with Bipolar

Disorder

35

2517 15 15

11 11 106

25

0

10

20

30

40

50

60

70

80

90

100

Hyp

erte

nsion

Dys

lipid

emia

Alc

ohol U

se d

/o

Dia

betes

Low B

ack

Pai

n

Arthri

tis IHD

CO

PD

Coca

ine

use

d/o

Hep

atiti

s C

%

Kilbourne AM, et al. Bipolar Disord 2004, 6: 368-373

Kilbourne AM, et al. Bipolar Disord 2004, 6: 368-373

Cross-Sectional Differences between BD, Schizophrenia, and NCs in neurocognitive

measures (age 44-85)

Lifespan Predictors of Greater Cognitive Impairment

+ Greater number of manic and depressive episodes

+ Greater number of hospitalizations

+ Longer duration of illness

= Possible “neurotoxicity” associated with symptom exacerbations

Robinson et al. 2008

Summary of Age-Associated Changes in Late Life BD

Positive Changes Negative Changes

Substance abuse Cognitive/functional impairment

Acuity of mania Depression remains?

Avoidance of treatment Medication/Medical

burden

External stressors/

Social conflict

Isolation

Applying successful aging to mental illnesses

• What are the characteristics of people who “succeed” despite having bipolar disorder?

• How do some patients “adapt well” to bipolar disorder?

Resilience in Bipolar Disorder

“Having a mental illness is like pushing a rock up a hill and it’s always coming back at you. People see mentally ill people as weak. To me, it takes even more strength than the average person has.”

– David 64 Year Old with Bipolar I

Overview• Brief broad background on population aging

• Aging and bipolar disorder

• Interventions for older adults with bipolar disorder

• Applying healthy aging concepts to bipolar disorder

• Summary and discussion

GERI-BD• Only clinical trial of any treatment in older

adults with BD

• Comparison of 9 weeks of Lithium or Valproate in adults older than age 60 in a Manic, Mixed, or Hypomanic Episode

• High prevalence of cardiovascular burden

• Results: Both treatments were effective with a low rate of adverse events

Young et al, 2010; 2013

Psychosocial Interventions for BD

• Cognitive-Behavioral Therapy (>8 RCTs)

• Family Focused Therapy (>4 RCTS)

• Interpersonal and Social Rhythms Therapy (>3 RCTs)

• Psychoeducation (>10 RCTs)

• Cognitive/Functional Remediation (1 RCTs)Scott 2005; Lam 2008; Beynon et al. 2008

General Adaptation Psychotherapy for Older Adults

1. Shorter (45 minute) and more sessions

2. Simpler, larger font worksheets

3. Physical illness and disability are the rule not the exception – need to collaborate with broader set of providers

4. Changes in cognition or mood have complex causes

5. Older adults often prefer psychotherapy

Medication Adherence Skills Training –BD (2008): Group Psychoeducation

Health Beliefs Model

Belief in Illness

(Need for medications)

Belief that Benefits ofMedication

Outweigh Costs

Use Cues to Engage in Behavior

ImmediateMemory

ProspectiveMemory

Longer-TermRecall

Cognitive Aging Model of Adherence

Rosenstock HA and Hansen DB. Am J Psychiatry 1974;131:1397-9.Brown SC and Park DC. Gerontologist 2003;43:57-67.

Pre-Post Change in Adherence

Depp CA, et al. Bipolar Disord 2008;9:636-45; (N=16)

Self Reported non-adherence to mood stabilizer in

the past week

0

5

10

15

20

25

30

35

40

45

50

Per

cen

t

Baseline

Post-Treatment

Self-reported trouble taking all of prescribed

medications

0

5

10

15

20

25

30

35

40

45

50

Per

cent

Baseline

Post-Treatment

Cognitive Tasks Following Self-Management Recommendations

• Typical psychoeducation:

– Increasing awareness of daily fluctuations

– Developing action plans in case of symptom exacerbation

– E.G. “When I get depressed, I will call a friend for support…”

• Successful implementation requires people to:

– Pay attention to their mood over time

– Remember what to do, when to do it, and why

– Engage in the plan outside of the clinic

– Engage in the plan when they feel worse but before the “#$%# hits the fan”Depp et al., 2010 JNMD

Personalized Real-Time Intervention for Stabilizing Mood (PRISM)

Goal: Transporting psychoeducation to real-time

Basis: Life Goals Manual (Bauer et al., 2009)

Intervention: 4 in-person sessions and subsequent responding on mobile phone

1. Identification of self-management strategies by phase of illness or early warning sign

2. Education on optimal ways of implementing strategy

3. Phrase self-management messages to self

Example Implementation Intentions

“If I am mildly manic …

I’ll give my motorcycle keys to [my wife] …

to be safe”

Situation/State

Specific

Behavior

Benefit

Gollwitzer and Sheeran (2006)

Personalized feedback

Data

Mood

Heart rateGPS/location/activity level

0

2

4

6

8

Week

Sampling Rate

Overview• Brief broad background on population aging

• Aging and bipolar disorder

• Interventions for older adults with bipolar disorder

• Applying healthy aging concepts to bipolar disorder

• Summary and discussion

Pessimistic View of Behavioral Determinants of Successful

Aging as Applied to BD

Behavioral Determinants of

Successful Aging

• Exercise

• Diet

• Cognitive stimulation

• Optimism/resilience

• Social integration

• Positive attitudes toward aging

• Stress reduction

Depression

Peak ages of physiological performance

• Hearing peaks at 5 years old

• Smell peaks at 10 years old

• Taste peaks at 10 years old

• Flexibility and balance peaks at 13 years old

• Muscle strength peaks at 18 years old

• Tissue repair peaks at 13 years old

• Short term memory peaks at 20 years old

• Immune response peaks at 13 years old

• Lung capacity peaks at 20 years old

Cutler and Mattson (2007) Ageing Res Reviews

Caloric Restriction: Extends the

Lifespan in Multiple Species

One for the Age: A prescription that may extend life. New York Times. (Oct 31, 2006).

Optimistic View of Modifiable Factors in Successful Aging

Potentially Modifiable Factors

in Successful Aging

• Exercise

• Diet

• Cognitive stimulation

• Optimism/resilience

• Social integration

• Positive attitudes toward aging

• Stress reduction

Depression

http://www.princeton.edu/~rpds/downloads/Deaton_Aging_and_wellbeing_around_the_world_Aug_07_ALL.pdf

Life Satisfaction by Age

Exercise as effective as antidepressants in

treating major depression in older adults

Blumenthal et al., JAMA 1999

Cognitive Training and Depression

Shared Mechanisms of Aging

Interventions

Mattson et al., 2002

Effect of a Healthy Lifestyle: Nurses Health Study (n=84,129)

Examined the effect of the following combination of behaviors:

• Not currently smoking

• Low/moderate alcohol consumption

• ½ hour of moderate physical activity per day

• Diet that was:

– High in cereal fiber

– High in marine n–3 fatty acids,

– High ratio of polyunsaturated to saturated fat

– Low in trans fat

– Low in glycemic loadN Engl J Med. 2000 Jul 6;343(1):16-22

Effect of a Healthy Lifestyle: Nurses Health Study (n=84,129)

Dietary score and risk for Heart Disease in women from the Nurses’Health Study.

Stampfer et al,6

N Engl J Med. 2000 Jul 6;343(1):16-22

BMI and Cognitive Ability in Serious Mental Illness

-1.4

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

Bipolar Disorder(n=341)

Schizophrenia(n=417)

Normal (BMI 18-25)

Overweight (BMI 25-30)

Obese (BMI 30+)

z-sc

ore

s (s

tan

der

r)

Depp et al., Bipolar Disord., In press

Smoking History and Cognitive Functioning

Depp et al., In Press

Summary of Modifiable Factors in Successful Aging

• Exercise

• Diet

• Mental activities

• Optimism

• Social integration

• Positive attitudes toward aging

• Stress reduction

• Regular health screenings

Summary• Many people with bipolar disorder are

older adults (and more are coming!)

• Treatment works but should be adapted to cognitive and physical changes

• Bioehavioral determinants of successful aging are:

– Negatively impacted by bipolar disorders AND

– Potential treatment targets in bipolar disorder

THANK YOU !!!aging.ucsd.edu