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Nielsen JL, Kaltoft K, Wium-Andersen IK, Wium-Andersen MK, Osler M. Association of early- and late-life bipolar disorder with incident dementia. A Danish cohort study. J Affect Disord 2024; 367:367-373. [PMID: 39242040 DOI: 10.1016/j.jad.2024.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND This study aimed to explore the association between bipolar disorder and the risk of developing dementia, and whether the risk varies with age at the onset of bipolar disorder. METHODS In this study, 37,084 individuals with a first-time diagnosis of bipolar disorder diagnosed between 1969 and 2018 and a reference population (n = 189,662) matched on sex, birth year and time of bipolar diagnosis (index date) were followed in nationwide registries for incident dementia until October 2020. Associations were analysed using Cox proportional hazard regression with adjustment for sex, education level, alcohol or drug abuse, traumatic brain injury, ischemic heart disease, stroke and diabetes mellitus. RESULTS In total, 6.6 % of individuals with bipolar disorder and 4.0 % in the reference population developed dementia during the mean follow-up of 13.1 years. Compared to the reference population, individuals with bipolar disorder had a higher incidence of dementia during follow-up after adjusting for potential confounders (HR: 2.66, 95 % CI [2.53-2.79]). The strength of this association did not vary among individuals diagnosed with bipolar disorder before and after age 45. LIMITATIONS The higher risk of dementia identified for individuals with bipolar disorder could be influenced by detection bias and, despite a large cohort, some of the age-stratified analyses were still affected by lack of statistical power. CONCLUSION Individuals with bipolar disorder have a higher risk of developing dementia compared to a reference population without bipolar disorder, independent of the age at the onset of bipolar disorder.
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Affiliation(s)
- Jane Lykke Nielsen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospitals, Frederiksberg, Copenhagen, Denmark
| | - Klara Kaltoft
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospitals, Frederiksberg, Copenhagen, Denmark
| | - Ida Kim Wium-Andersen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospitals, Frederiksberg, Copenhagen, Denmark
| | - Marie Kim Wium-Andersen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospitals, Frederiksberg, Copenhagen, Denmark
| | - Merete Osler
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospitals, Frederiksberg, Copenhagen, Denmark; Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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Liu CC, Lin CY, Liu CH, Chang KC, Wang SK, Wang JY. Bidirectional association between major depressive disorder and dementia: Two population-based cohort studies in Taiwan. Compr Psychiatry 2023; 127:152411. [PMID: 37722203 DOI: 10.1016/j.comppsych.2023.152411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Major depressive disorder (MDD) and dementia are both major contributors to the global burden of disease. Despite existing literature on the association between MDD and dementia, there is a lack of a nationwide longitudinal cohort study that considers the competing risk of death. Therefore, this study assessed the bidirectional associations between MDD and dementia over an 11-year period in population-based settings, accounting for death as a competing risk. METHODS We conducted two population-based retrospective cohort studies in Taiwan. We identified 80,742 patients diagnosed with MDD in 2009-2010 and matched them with patients without MDD by sex, age, and year of diagnosis to assess the relative risk of dementia. We also identified 80,108 patients diagnosed with dementia in 2009-2010 and matched them with patients without dementia by sex, age, and year of diagnosis to assess the relative risk of MDD. All patients were followed until they received a diagnosis of new onset MDD or new onset dementia, their death, or the end of 2019. Cause-specific hazards models were used to estimate adjusted hazard ratios (aHRs). RESULTS The incidence density (ID) of dementia was higher in patients with MDD than in patients without MDD (7.63 vs. 2.99 per 1000 person-years), with an aHR of 2.71 (95% confidence interval [CI]: 2.55-2.88). The ID of MDD was higher in patients with dementia than in patients without dementia (12.77 vs. 4.69 per 1000 person-years), with an aHR of 2.47 (95% CI: 2.35-2.59). CONCLUSIONS This population-based study found a bidirectional association between MDD and dementia. Our findings suggest the need to identify dementia in patients with MDD and vice versa.
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Affiliation(s)
- Chih-Ching Liu
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taiwan.
| | - Chih-Yuan Lin
- Department of Neurology, Taipei City Hospital, Linsen Chinese Medicine Branch, Taipei, Taiwan; Institute of Health and Welfare Policy, School of Medicine, National Yang Ming Chiao Tung University, Taiwan
| | - Chien-Hui Liu
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taiwan; Division of Emergency Medical Service, New Taipei City Fire Department, New Taipei City, Taiwan
| | - Kun-Chia Chang
- Jianan Psychiatric Center, Ministry of Health and Welfare, Taiwan; Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Kai Wang
- Department of Pediatrics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Jiun-Yi Wang
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taiwan; Department of Medical Research, China Medical University Hospital, China Medical University, Taiwan.
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Ochi S, Mori T, Iga JI, Ueno SI. Prevalence of Comorbid Dementia in Late-life Depression and Bipolar Disorder: A Retrospective Inpatient Study. J Alzheimers Dis Rep 2022; 6:589-598. [PMID: 36275416 PMCID: PMC9535605 DOI: 10.3233/adr-220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Dementia in patients with late-life mood disorders is clinically important. Objective: We aimed to investigate the prevalence of dementia in patients with late-life major depressive disorder (MDD) or bipolar disorder (BD) and to clarify the clinical characteristics associated with the diagnosis of dementia. Methods: The prevalence of dementia at hospital discharge and the clinical characteristics at hospitalization who are diagnosed with MDD or BD over 65 years of age, from the medical records of 684 patients who had been admitted from 2015 to 2020 were investigated. Results: A total of 66 patients with MDD (n = 50) and BD (n = 16) were analyzed. The prevalence of dementia was significantly higher in MDD than in BD (24.0% versus 0%; p = 0.026). The mean age at onset of MDD was significantly older in the MDD with dementia group than in the MDD without (76.9±6.3 years versus 62.2±14.0 years; p < 0.001). The rate of first depressive episode at this admission was significantly higher in the MDD with dementia group (91.7% versus 30.3%; p < 0.001). The diagnosis of dementia was significantly associated with lower scores for “insomnia early” (p = 0.019) and higher scores for “insight” (p = 0.049) on the 17-item Hamilton Depression Rating (HAMD-17) subscales and lower scores for “recall” (p = 0.003) on the MMSE subscales. Conclusion: The older age of first onset of depression, “insomnia early”, “insight” and “recall” may be useful indicators for a diagnosis of dementia in late-life depression.
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Affiliation(s)
- Shinichiro Ochi
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takaaki Mori
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Jun-ichi Iga
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Shu-ichi Ueno
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Stafford J, Chung WT, Sommerlad A, Kirkbride JB, Howard R. Psychiatric disorders and risk of subsequent dementia: Systematic review and meta-analysis of longitudinal studies. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5711. [PMID: 35460299 PMCID: PMC9325434 DOI: 10.1002/gps.5711] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Although psychiatric disorders have been found to be associated with increased risk of dementia, previous findings are mixed, and the nature of these relationships remains poorly understood. We examined longitudinal associations between depression, anxiety, post-traumatic stress disorders (PTSD), bipolar disorder (BPD), psychotic disorders and subsequent dementia. METHODS We searched three databases for longitudinal, population-based studies investigating associations between psychiatric disorders and dementia (PROSPERO registration: CRD42020209638). We conducted narrative synthesis, and random-effects meta-analyses to obtain pooled estimates. We used meta-regression and stratified analyses to examine variation by sex, age-at-onset and follow-up time. RESULTS Fifty-seven citations met eligibility criteria. Most studies focussed on depression (n = 33), which was associated with subsequent all-cause dementia (pooled relative risk [RR]: 1.96, 95% confidence interval [CI]: 1.59-2.43; I2 = 96.5%), Alzheimer's Disease (pooled RR: 1.9, 95% CI: 1.52-2.38; I2 = 85.5%), and Vascular Dementia (pooled RR: 2.71, 95% CI: 2.48-2.97; I2 = 0). Associations were stronger in studies with shorter follow-up periods and for severe and late-onset depression. Findings regarding anxiety were mixed, and we did not find evidence of an overall association (pooled RR: 1.18, 95% CI: 0.96-1.45; I2 = 52.2%, n = 5). Despite sparse evidence, psychotic disorders (pooled RR: 2.19, 95% CI: 1.44-3.31; I2 = 99%), PTSD and BPD were associated with subsequent dementia. CONCLUSIONS People with psychiatric disorders represent high-risk groups for dementia, highlighting the importance of ongoing symptom monitoring in these groups. Findings regarding temporality and age-at-onset indicate that depression symptoms could reflect prodromal dementia for some individuals. Further longitudinal research is required to determine whether psychiatric disorders represent causal risk factors or early markers of dementia neuropathology.
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Affiliation(s)
- Jean Stafford
- MRC Unit for Lifelong Health and AgeingUniversity College London (UCL)LondonUK
| | - Wing Tung Chung
- Division of PsychiatryUniversity College London (UCL)LondonUK
| | | | | | - Robert Howard
- Division of PsychiatryUniversity College London (UCL)LondonUK
- Camden and Islington NHS Foundation TrustLondonUK
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Chen Y, Chu H, Wang P. Employee Assistance Programs: A Meta‐Analysis. JOURNAL OF EMPLOYMENT COUNSELING 2021. [DOI: 10.1002/joec.12170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yin‐Che Chen
- Department of Educational Psychology and Counseling National Tsing Hua University
| | - Hui‐Chuang Chu
- Department of Educational Psychology and Counseling National Tsing Hua University
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Characteristics of Bipolar Patients with Cognitive Impairment of Suspected Neurodegenerative Origin: A Multicenter Cohort. J Pers Med 2021; 11:jpm11111183. [PMID: 34834535 PMCID: PMC8620397 DOI: 10.3390/jpm11111183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/29/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Bipolar disorder is associated with an increased risk of dementia with aging. Little is known regarding this association, limiting appropriate diagnosis and management. We aimed to describe the characteristics of bipolar patients with late cognitive impairment for whom the hypothesis of an underlying neurodegenerative disease had been raised. We performed a retrospective multicenter study, recruiting bipolar patients over 50 years old from five French tertiary memory centers who had undergone cerebrospinal fluid (CSF) biomarker assessment for Alzheimer’s disease (AD). Clinical, neuropsychological, and paraclinical characteristics were analyzed and 78 patients were included. The mean age at the onset of cognitive impairment was 62.4 years (±9.2). The mean MMSE score was 22.8 (±4.5), the mean FAB was 11.7 (±3.9), and the mean FCRST was 15.8 (±7.4)/36.8 (±9.7) (free/total recall). A total of 48.6% of the patients displayed cognitive fluctuations, and 38.2% showed cognitive improvement during follow-ups; and 56.3% of the patients showed Parkinsonism, of which 12.7% had never received antipsychotics. Among patients who underwent DAT-scans, 35.3% displayed dopaminergic denervation; 10.3% of patients had CSF AD biological signature (“A+ T+” profile), while 56.4% had other abnormal CSF profiles. Thus, clinical presentation was dominated by executive dysfunction, episodic memory impairment, fluctuating cognition, and a high frequency of Parkinsonism. Specifically, high frequency of delusional episodes suggests limited tolerance of psychotropic drugs. Most patients had abnormal CSF biomarker profiles, but only a minority displayed AD’s specific biomarker signature. Therefore, while our results unveil shared common neurocognitive features in bipolar patients with cognitive impairment of suspected neurodegenerative origin they suggest a participation of various underlying pathologies rather than a common degenerative mechanism in the pathophysiology of this condition.
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Beunders AJM, Kemp T, Korten NCM, Oudega ML, Beekman ATF, Kupka RW, Stek ML, Schouws SNTM, Dols A. Cognitive performance in older-age bipolar disorder: Investigating psychiatric characteristics, cardiovascular burden and psychotropic medication. Acta Psychiatr Scand 2021; 144:392-406. [PMID: 34166526 PMCID: PMC8518600 DOI: 10.1111/acps.13342] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/20/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to explore a large range of candidate determinants of cognitive performance in older-age bipolar disorder (OABD). METHODS A cross-sectional study was performed in 172 BD patients aged ≥50 years. Demographics, psychiatric characteristics and psychotropic medication use were collected using self-report questionnaires and structured interviews. The presence of cardiovascular risk factors was determined by combining information from structured interviews, physical examination and laboratory assessments. Cognitive performance was investigated by an extensive neuropsychological assessment of 13 tests, covering the domains of attention, learning/ memory, verbal fluency and executive functioning. The average of 13 neuropsychological test Z-scores resulted in a composite cognitive score. A linear multiple regression model was created using forward selection with the composite cognitive score as outcome variable. Domain cognitive scores were used as secondary outcome variables. RESULTS The final multivariable model (N = 125), which controlled for age and education level, included number of depressive episodes, number of (hypo)manic episodes, late onset, five or more psychiatric admissions, lifetime smoking, metabolic syndrome and current use of benzodiazepines. Together, these determinants explained 43.0% of the variance in composite cognitive score. Late onset and number of depressive episodes were significantly related to better cognitive performance whereas five or more psychiatric admissions and benzodiazepine use were significantly related to worse cognitive performance. CONCLUSION Psychiatric characteristics, cardiovascular risk and benzodiazepine use are related to cognitive performance in OABD. Cognitive variability in OABD thus seems multifactorial. Strategies aimed at improving cognition in BD should include cardiovascular risk management and minimizing benzodiazepine use.
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Affiliation(s)
- Alexandra J. M. Beunders
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Tokie Kemp
- GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Nicole C. M. Korten
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Mardien L. Oudega
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Aartjan T. F. Beekman
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Ralph W. Kupka
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Max L. Stek
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Sigfried N. T. M. Schouws
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands
| | - Annemiek Dols
- Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Public Health Research InstituteAmsterdamThe Netherlands,GGZ inGeest Specialized Mental Health CareAmsterdamThe Netherlands,Amsterdam UMCVrije UniversiteitPsychiatryAmsterdam Neuroscience Research InstituteAmsterdamThe Netherlands
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Mendez MF. Degenerative dementias: Alterations of emotions and mood disorders. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:261-281. [PMID: 34389121 DOI: 10.1016/b978-0-12-822290-4.00012-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Degenerative dementias such as Alzheimer's disease and frontotemporal dementia result in distinct alterations in emotional processing, emotional experiences, and mood. The neuropathology of these dementias extends to structures involved in emotional processing, including the basolateral limbic network (orbitofrontal cortex, anterior temporal lobe, amygdala, and thalamus), the insula, and ventromedial frontal lobe. Depression is the most common emotion and mood disorder affecting patients with Alzheimer's disease. The onset of depression can be a prodromal sign of this dementia. Anxiety can also be present early in the course of Alzheimer's disease and especially among patients with early-onset forms of the disease. In contrast, patients with behavioral variant frontotemporal dementia demonstrate hypoemotionality, deficits in the recognition of emotion, and decreased psychophysiological reactivity to emotional stimuli. They typically have a disproportionate impairment in emotional and cognitive empathy. One other unique feature of behavioral variant frontotemporal dementia is the frequent occurrence of bipolar disorder. The management strategies for these alterations of emotion and mood in degenerative dementias primarily involve the judicious use of the psychiatric armamentarium of medications.
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Affiliation(s)
- Mario F Mendez
- Behavioral Neurology Program, Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States; Neurology Service, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States.
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Abstract
OBJECTIVE Previous studies have documented manic and hypomanic symptoms in behavioral variant frontotemporal dementia (bvFTD), suggesting a relationship between bipolar disorder and bvFTD. METHODS The investigators conducted a literature review as well as a review of the psychiatric histories of 137 patients with bvFTD, and patients with a prior diagnosis of bipolar disorder were identified. The clinical characteristics of patients' bipolar disorder diagnosis, family history, features of bvFTD, and results from fluorodeoxyglucose positron emission tomography (FDG-PET), as well as autopsy findings, were evaluated. RESULTS Among the 137 patients, 14 (10.2%) had a psychiatric diagnosis of bipolar disorder, eight of whom met criteria for bipolar disorder (type I, N=6; type II, N=2) 6-12 years preceding onset of classic symptoms of progressive bvFTD. Seven of the eight patients with bipolar disorder had a family history of mood disorders, four had bitemporal predominant hypometabolism on FDG-PET, and two had a tauopathy involving temporal lobes on autopsy. Three additional patients with late-onset bipolar I disorder proved to have a nonprogressive disorder mimicking bvFTD. The remaining three patients with bvFTD had prior psychiatric symptoms that did not meet criteria for a diagnosis of bipolar disorder. The literature review and the findings for one patient further suggested a shared genetic mutation in some patients. CONCLUSIONS Manic or hypomanic episodes years before other symptoms of bvFTD may be a prodrome of this dementia, possibly indicating anterior temporal involvement in bvFTD. Other patients with late-onset bipolar disorder exhibit the nonprogressive frontotemporal dementia phenocopy syndrome. Finally, a few patients with bvFTD have a genetic predisposition for both disorders.
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Affiliation(s)
- Mario F. Mendez
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles
- Departments of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles
- V.A. Greater Los Angeles Healthcare System, Los Angeles, California
| | - Leila Parand
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles
- V.A. Greater Los Angeles Healthcare System, Los Angeles, California
| | - Golnoush Akhlaghipour
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles
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Diniz BS, Lavretsky H, Karp JF, Rutherford B, Mulsant B, Lenze E. Mood Disorders and Dementia: Time for Action. Am J Geriatr Psychiatry 2020; 28:542-544. [PMID: 31843380 DOI: 10.1016/j.jagp.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Breno S Diniz
- Department of Psychiatry, Faculty of Medicine, University of Toronto & Adult Neurodevelopment and Geriatric Psychiatry Division, Centre for Addiction and Mental Health (BSD, BM), Toronto, ON, Canada.
| | - Helen Lavretsky
- Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, UCLA (HL), Los Angeles, CA
| | - Jordan F Karp
- Department of Psychiatry, School of Medicine, University of Pittsburgh (JFK), Pittsburgh, PA
| | - Bret Rutherford
- Department of Psychiatry, Columbia University (BR), New York, NY
| | - Benoit Mulsant
- Department of Psychiatry, Faculty of Medicine, University of Toronto & Adult Neurodevelopment and Geriatric Psychiatry Division, Centre for Addiction and Mental Health (BSD, BM), Toronto, ON, Canada
| | - Eric Lenze
- Deprtment of Psychiatry, Washington University School of Medicine (EL), St Louis, MO
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