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Christl J, Supprian T. [Lithium treatment for affective disorders in old age]. DER NERVENARZT 2024; 95:41-45. [PMID: 38189940 DOI: 10.1007/s00115-023-01601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Lithium is considered the gold standard for the treatment of bipolar affective disorder for the prevention of recurrence of manic and depressive episodes and for augmentation treatment in unipolar severe depressive episodes. The indications for treatment with lithium do not differ for older or younger patients. Nevertheless, there are a number of aspects to be considered with respect to drug safety in the group of old patients. OBJECTIVE The aim was to give an overview of the current literature on lithium treatment in old age and from this to derive recommendations for action. MATERIAL AND METHODS A selective literature review on lithium treatment in old age was conducted to answer questions on drug safety, monitoring (particularly with respect to comorbidities) and potential alternatives to lithium. RESULTS AND DISCUSSION Lithium is an effective and, if used correctly, safe drug also in old people; however, with respect to somatic comorbidities that increase with age, special caution is required when using lithium in order to prevent nephropathy and intoxication.
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Affiliation(s)
- Julia Christl
- Abteilung Gerontopsychiatrie, LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf, Bergische Landstr. 2, 40629, Düsseldorf, Deutschland.
| | - Tillmann Supprian
- Abteilung Gerontopsychiatrie, LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf, Bergische Landstr. 2, 40629, Düsseldorf, Deutschland
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Dols A, Sekhon H, Rej S, Klaus F, Bodenstein K, Sajatovic M. Bipolar Disorder Among Older Adults: Newer Evidence to Guide Clinical Practice. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:370-379. [PMID: 38695001 PMCID: PMC11058954 DOI: 10.1176/appi.focus.20230010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
The term older-age bipolar disorder (OABD) refers to patients with bipolar disorder who are ages 50 and older. Research findings suggest important differences, including the attenuation of manic symptoms with age and the occurrence of multiple somatic comorbid conditions. Although the pharmacological treatment of OABD is fairly similar, adverse effects, somatic comorbidity, and drug-drug interactions are more common. Lithium is effective in treating OABD and may have the potential to be neuroprotective. Anticonvulsants and second-generation antipsychotics have a growing evidence supporting their use in treating OABD. Behavioral intervention can be a helpful adjunct to pharmacological treatment. Clinicians and health care systems need to be prepared to provide care and services to individuals with bipolar disorder throughout the life span. Although older adults have typically been excluded from bipolar disorder RCTs, emerging efforts organized by global advocates and harnessing teams of clinicians and scientists have the potential to advance care.
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Affiliation(s)
- Annemiek Dols
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands (Dols); Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montreal, Quebec, Canada (Sekhon, Rej, Bodenstein); McLean Hospital (Harvard Medical School Affiliate), Belmont, Massachusetts (Sekhon); Department of Psychiatry, University of California, San Diego, La Jolla, California (Klaus); Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Sajatovic)
| | - Harmehr Sekhon
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands (Dols); Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montreal, Quebec, Canada (Sekhon, Rej, Bodenstein); McLean Hospital (Harvard Medical School Affiliate), Belmont, Massachusetts (Sekhon); Department of Psychiatry, University of California, San Diego, La Jolla, California (Klaus); Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Sajatovic)
| | - Soham Rej
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands (Dols); Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montreal, Quebec, Canada (Sekhon, Rej, Bodenstein); McLean Hospital (Harvard Medical School Affiliate), Belmont, Massachusetts (Sekhon); Department of Psychiatry, University of California, San Diego, La Jolla, California (Klaus); Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Sajatovic)
| | - Federica Klaus
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands (Dols); Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montreal, Quebec, Canada (Sekhon, Rej, Bodenstein); McLean Hospital (Harvard Medical School Affiliate), Belmont, Massachusetts (Sekhon); Department of Psychiatry, University of California, San Diego, La Jolla, California (Klaus); Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Sajatovic)
| | - Katie Bodenstein
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands (Dols); Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montreal, Quebec, Canada (Sekhon, Rej, Bodenstein); McLean Hospital (Harvard Medical School Affiliate), Belmont, Massachusetts (Sekhon); Department of Psychiatry, University of California, San Diego, La Jolla, California (Klaus); Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Sajatovic)
| | - Martha Sajatovic
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands (Dols); Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montreal, Quebec, Canada (Sekhon, Rej, Bodenstein); McLean Hospital (Harvard Medical School Affiliate), Belmont, Massachusetts (Sekhon); Department of Psychiatry, University of California, San Diego, La Jolla, California (Klaus); Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Sajatovic)
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Ljubic N, Ueberberg B, Grunze H, Assion HJ. Treatment of Bipolar Disorders in Older Adults: A Review. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:434-443. [PMID: 38695000 PMCID: PMC11058944 DOI: 10.1176/appi.focus.23021024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Background Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly. Methods We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Summary of findings Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, moodstabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD. Conclusions There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.Appeared originally in Ann Gen Psychiatry 2021; 20:1.
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Affiliation(s)
- Nemanja Ljubic
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287 Dortmund, Germany (Ljubic, Ueberberg, Assion); Psychiatrie Schwäbisch Hall, Ringstraße. 1, 74523 Schwäbisch Hall, Germany (Grunze); Paracelsus Medical University, Ernst-Nathan Straße 1, 90419 Nuremberg, Germany (Grunze)
| | - Bianca Ueberberg
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287 Dortmund, Germany (Ljubic, Ueberberg, Assion); Psychiatrie Schwäbisch Hall, Ringstraße. 1, 74523 Schwäbisch Hall, Germany (Grunze); Paracelsus Medical University, Ernst-Nathan Straße 1, 90419 Nuremberg, Germany (Grunze)
| | - Heinz Grunze
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287 Dortmund, Germany (Ljubic, Ueberberg, Assion); Psychiatrie Schwäbisch Hall, Ringstraße. 1, 74523 Schwäbisch Hall, Germany (Grunze); Paracelsus Medical University, Ernst-Nathan Straße 1, 90419 Nuremberg, Germany (Grunze)
| | - Hans-Jörg Assion
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287 Dortmund, Germany (Ljubic, Ueberberg, Assion); Psychiatrie Schwäbisch Hall, Ringstraße. 1, 74523 Schwäbisch Hall, Germany (Grunze); Paracelsus Medical University, Ernst-Nathan Straße 1, 90419 Nuremberg, Germany (Grunze)
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Christl J, Müller-Oerlinghausen B, Bauer M, Kamp D, Fußer F, Benninghoff J, Fehrenbach RA, Lange-Asschenfeldt C, Rapp M, Ibach B, Schaub R, Wollmer A, Strotmann-Tack T, Hüll M, Biermann S, Roscher K, Meissnest B, Menges A, Weigel B, Maliszewski-Makowka D, Mauerer C, Schaefer M, Joachimsmeier B, Kayser S, Rump LC, Supprian T. Lithium Therapy in Old Age: Recommendations from a Delphi Survey. PHARMACOPSYCHIATRY 2023; 56:188-196. [PMID: 37506737 PMCID: PMC10484639 DOI: 10.1055/a-2117-5200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/16/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION While lithium (Li) has been well established for the treatment of bipolar disorder, geriatric patients require special attention when it comes to issues of drug safety. Declining renal function, amongst other medical conditions, and polypharmacy may pose increased risks. Only a few previous studies have addressed the management of Li in geriatric patients. METHODS Twenty-four German medical experts on geriatric medicine and Li treatment participated in a Delphi survey, consisting of two rounds of questionnaires and a final formulation of treatment recommendations. Three major issues of Li therapy were outlined: initiation of treatment, monitoring of ongoing therapy, and withdrawal due to medical reasons. Final recommendations were consented to at a threshold of at least 80% expert agreement. RESULTS Final consensus was achieved on 21 clinical recommendations. The approved recommendations covered aspects of necessary laboratory checks, concomitant medication, and target Li serum concentration in geriatric patients. Concerning the termination of Li therapy, an agreement was reached on the appropriate time span for tapering and on potential alternatives to Li. No consensus was achieved on whether concomitant dementia or frailty should be considered contraindications for Li treatment and the appropriate threshold of the estimated glomerular function rate for withdrawing Li. CONCLUSION According to the view of German experts, Li may be used in geriatric patients, but it should be monitored carefully. However, the lack of consent in several specific treatment situations underlines the need for research on specific issues of Li therapy.
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Affiliation(s)
- Julia Christl
- Department of Psychiatry and Psychotherapy, Medical Faculty,
Heinrich-Heine-University, Düsseldorf, Germany
| | - Bruno Müller-Oerlinghausen
- Charité Universitätsmedizin Berlin, Berlin,
Germany
- Brandenburg Medical School Theodor Fontane, Faculty of Medicine and
Psychology, Neuruppin, Germany
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl
Gustav Carus, Medical Faculty, Technische Universität Dresden, Dresden,
Germany
| | - Daniel Kamp
- Department of Psychiatry and Psychotherapy, Medical Faculty,
Heinrich-Heine-University, Düsseldorf, Germany
| | - Fabian Fußer
- Klinik für Gerontopsychiatrie, Psychosomatik und
Psychotherapie, Pfalzklinikum Klingenmünster, Klingenmünster,
Germany
| | - Jens Benninghoff
- Zentrum für Altersmedizin und Entwicklungsstörungen,
kbo-Isar-Amper-Klinikum München-Ost, Haar, Germany
- LVR-Universitätsklinik Essen, Kliniken und Institut der
Universität Duisburg-Essen, Essen, Germany
| | - Rosa A. Fehrenbach
- Saarland-Heilstätten GmbH, SHG-Kliniken Sonnenberg, Klinik
für Gerontopsychiatrie, Saarbrücken, Germany
| | - Christian Lange-Asschenfeldt
- Department of Psychiatry and Psychotherapy, Medical Faculty,
Heinrich-Heine-University, Düsseldorf, Germany
- Oberberg Fachklinik Düsseldorf Kaarst, Kaarst,
Germany
| | - Michael Rapp
- University of Potsdam, Research Area Cognitive Sciences, Division of
Social and Preventive Medicine, Potsdam, Germany
| | - Bernd Ibach
- Zentrum für Alterspsychiatrie und Privé, Clienia
Littenheid AG, Littenheid und Universität Zürich,
Zürich, Schweiz
| | - Rainer Schaub
- Klinik für Gerontopsychiatrie und Psychotherapie, Klinikum am
Weissenhof, Weinsberg, Germany
| | - Axel Wollmer
- Klinik für Gerontopsychiatrie und Psychotherapie, Asklepios
Klinik Nord-Ochsenzoll, Hamburg, Germany
| | - Timm Strotmann-Tack
- Klinik für Gerontopsychiatrie und Psychotherapie, LVR-Klinik
Viersen, Viersen, Germany
| | - Michael Hüll
- Zentrum für Psychiatrie Emmendingen, Emmendingen,
Germany
| | | | | | | | | | - Bernd Weigel
- Bezirksklinikum Mainkofen, Mainkofen, Deggendorf, Germany
| | | | | | - Martin Schaefer
- Klinik für Psychiatrie, Psychotherapie, Psychosomatik und
Suchtmedizin, Evang. Kliniken Essen-Mitte, Essen, Germany
| | | | - Sarah Kayser
- Klinik für Allgemeine Psychiatrie und Psychotherapie mit
Poliklinik Universitätsklinikum Tübingen, Tübingen,
Germany
| | - Lars Christian Rump
- Department of Nephrology, Medical Faculty, University Hospital
Düsseldorf, Heinrich-Heine-University Düsseldorf,
Düsseldorf, Germany
| | - Tillmann Supprian
- Department of Psychiatry and Psychotherapy, Medical Faculty,
Heinrich-Heine-University, Düsseldorf, Germany
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[Lithium treatment for affective disorders in old age]. Z Gerontol Geriatr 2023; 56:113-117. [PMID: 36879066 DOI: 10.1007/s00391-023-02164-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/13/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Lithium is considered the gold standard for the treatment of bipolar affective disorder for the prevention of recurrence of manic and depressive episodes and for augmentation treatment in unipolar severe depressive episodes. The indications for treatment with lithium do not differ for older or younger patients. Nevertheless, there are a number of aspects to be considered with respect to drug safety in the group of old patients. OBJECTIVE The aim was to give an overview of the current literature on lithium treatment in old age and from this to derive recommendations for action. MATERIAL AND METHODS A selective literature review on lithium treatment in old age was conducted to answer questions on drug safety, monitoring (particularly with respect to comorbidities) and potential alternatives to lithium. RESULTS AND DISCUSSION Lithium is an effective and, if used correctly, safe drug also in old people; however, with respect to somatic comorbidities that increase with age, special caution is required when using lithium in order to prevent nephropathy and intoxication.
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Ljubic N, Ueberberg B, Grunze H, Assion HJ. Treatment of bipolar disorders in older adults: a review. Ann Gen Psychiatry 2021; 20:45. [PMID: 34548077 PMCID: PMC8456640 DOI: 10.1186/s12991-021-00367-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly. METHODS We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD. CONCLUSIONS There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.
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Affiliation(s)
- Nemanja Ljubic
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287, Dortmund, Germany
| | - Bianca Ueberberg
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287, Dortmund, Germany
| | - Heinz Grunze
- Psychiatrie Schwäbisch Hall, Ringstraße. 1, 74523, Schwäbisch Hall, Germany.
- Paracelsus Medical University, Ernst-Nathan Straße 1, 90419, Nuremberg, Germany.
| | - Hans-Jörg Assion
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287, Dortmund, Germany
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Arnold I, Dehning J, Grunze A, Hausmann A. Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment. ACTA ACUST UNITED AC 2021; 57:medicina57060587. [PMID: 34201098 PMCID: PMC8226928 DOI: 10.3390/medicina57060587] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/27/2021] [Accepted: 06/04/2021] [Indexed: 01/10/2023]
Abstract
Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called “late onset” patients (LOBD), and the elder patients with a long-standing clinical history, the so called “early onset” patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970–2021 using the MeSH terms “bipolar disorder” and “aged” or “geriatric” or “elderly”. The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.
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Affiliation(s)
- Ivan Arnold
- Helios Klinik Berlin-Buch, 13125 Berlin, Germany;
| | - Julia Dehning
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-512-504-83802
| | - Anna Grunze
- Psychiatrisches Zentrum Nordbaden, 69168 Wiesloch, Germany;
| | - Armand Hausmann
- Private Practice, Wilhelm-Greil-Straße 5, 6020 Innsbruck, Austria;
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Tampi RR, Joshi P, Bhattacharya G, Gupta S. Evaluation and treatment of older-age bipolar disorder: a narrative review. Drugs Context 2021; 10:dic-2021-1-8. [PMID: 34113387 PMCID: PMC8166731 DOI: 10.7573/dic.2021-1-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/26/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives This narrative review aims to synthesize information from the literature regarding older-age bipolar disorder (OABD) in order to provide up-to-date information on this important illness. Methods We searched Ovid (Medline, Embase and PsychInfo) on October 1, 2020, using the keywords “bipolar disorder”, “older adults” and “elderly” to identify relevant articles on OABD. Additionally, the bibliography of identified articles was reviewed for pertinent studies. Discussions OABD is a term that is used to describe bipolar disorder (BD) occurring amongst individuals ≥50 years of age. Evidence indicates that OABD accounts for a quarter of all cases of BD. When compared to individuals with early-onset BD, individuals with OABD have a greater association with cerebrovascular disease and other neurological disorders, less family history of mood disorders, and utilize almost four times the total amount of mental health services. In addition, they are four times more likely to have psychiatric hospitalizations when compared to age-matched controls. Despite a dearth of controlled studies on the use of pharmacotherapy amongst individuals with OABD, available evidence from mixed-age studies indicates the efficacy of commonly used medications in individuals with early-onset BD. Additionally, psychosocial treatments have been found to be effective as adjunctive management strategies amongst individuals with OABD. Furthermore, electroconvulsive therapy may be effective in the treatment of refractory cases of OABD. Conclusions There is a great need for an improved understanding of the phenomenology and neurobiology of OABD. Additionally, research into effective treatments for this serious psychiatric disorder will mitigate the suffering of individuals with OABD.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Pallavi Joshi
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Gargi Bhattacharya
- Department of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, USA
| | - Sheila Gupta
- Department of Biochemistry, Jacobs School of Medicine and Biomedical Sciences, Buffalo NY, USA
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Reddy Mukku S, Nadella R, Kornapalli S. Cariprazine for late-life psychiatric illness: A review on therapeutic potential and challenges. JOURNAL OF GERIATRIC MENTAL HEALTH 2021. [DOI: 10.4103/jgmh.jgmh_43_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Lithium is the gold-standard treatment for bipolar disorder, and is effective in the management of manic, depressive, and maintenance phases of bipolar disorder treatment. Despite this, the implications of lithium use in the older population remain less understood. This critical narrative review aims to better understand the impact of lithium in older age bipolar disorder (OABD), including tolerability and efficacy, based on up-to-date evidence. Relevant studies of efficacy, effectiveness, and tolerability published any time prior to May 2018 were identified using the PubMed keyword search "lithium older adult bipolar disorder" and references from recent international bipolar disorder guidelines. One randomized controlled trial was identified, the GERI-BD (Acute Pharmacotherapy in Late-Life Mania) study. This study found lithium to be effective in late-life mania and hypomania. The remaining literature examining lithium in OABD was reviewed, comprising of a number of small open-label and retrospective studies, with special considerations highlighted. In summary, there is a small yet increasing geriatric evidence base that lithium is effective in OABD. Although there can be adverse effects with lithium, it is generally well tolerated, and there are methods to minimize these risks. Further research would strengthen the evidence base for lithium therapy in OABD. In the meantime, lithium remains the gold-standard treatment for OABD.
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Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, Sharma V, Goldstein BI, Rej S, Beaulieu S, Alda M, MacQueen G, Milev RV, Ravindran A, O'Donovan C, McIntosh D, Lam RW, Vazquez G, Kapczinski F, McIntyre RS, Kozicky J, Kanba S, Lafer B, Suppes T, Calabrese JR, Vieta E, Malhi G, Post RM, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord 2018; 20:97-170. [PMID: 29536616 PMCID: PMC5947163 DOI: 10.1111/bdi.12609] [Citation(s) in RCA: 952] [Impact Index Per Article: 158.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022]
Abstract
The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.
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Affiliation(s)
- Lakshmi N Yatham
- Department of PsychiatryUniversity of British ColumbiaVancouverBCCanada
| | | | - Sagar V Parikh
- Department of PsychiatryUniversity of MichiganAnn ArborMIUSA
| | - Ayal Schaffer
- Department of PsychiatryUniversity of TorontoTorontoONCanada
| | - David J Bond
- Department of PsychiatryUniversity of MinnesotaMinneapolisMNUSA
| | - Benicio N Frey
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada
| | - Verinder Sharma
- Departments of Psychiatry and Obstetrics & GynaecologyWestern UniversityLondonONCanada
| | | | - Soham Rej
- Department of PsychiatryMcGill UniversityMontrealQCCanada
| | - Serge Beaulieu
- Department of PsychiatryMcGill UniversityMontrealQCCanada
| | - Martin Alda
- Department of PsychiatryDalhousie UniversityHalifaxNSCanada
| | - Glenda MacQueen
- Department of PsychiatryUniversity of CalgaryCalgaryABCanada
| | - Roumen V Milev
- Departments of Psychiatry and PsychologyQueen's UniversityKingstonONCanada
| | - Arun Ravindran
- Department of PsychiatryUniversity of TorontoTorontoONCanada
| | | | - Diane McIntosh
- Department of PsychiatryUniversity of British ColumbiaVancouverBCCanada
| | - Raymond W Lam
- Department of PsychiatryUniversity of British ColumbiaVancouverBCCanada
| | - Gustavo Vazquez
- Departments of Psychiatry and PsychologyQueen's UniversityKingstonONCanada
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada
| | | | - Jan Kozicky
- School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
| | | | - Beny Lafer
- Department of PsychiatryUniversity of Sao PauloSao PauloBrazil
| | - Trisha Suppes
- Bipolar and Depression Research ProgramVA Palo AltoDepartment of Psychiatry & Behavioral Sciences Stanford UniversityStanfordCAUSA
| | - Joseph R Calabrese
- Department of PsychiatryUniversity Hospitals Case Medical CenterCase Western Reserve UniversityClevelandOHUSA
| | - Eduard Vieta
- Bipolar UnitInstitute of NeuroscienceHospital ClinicUniversity of BarcelonaIDIBAPS, CIBERSAMBarcelonaCataloniaSpain
| | - Gin Malhi
- Department of PsychiatryUniversity of SydneySydneyNSWAustralia
| | - Robert M Post
- Department of PsychiatryGeorge Washington UniversityWashingtonDCUSA
| | - Michael Berk
- Deakin UniveristyIMPACT Strategic Research CentreSchool of Medicine, Barwon HealthGeelongVic.Australia
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12
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Abstract
PURPOSE OF REVIEW The population over age 60 is growing more rapidly than the general population. Given the projected increase and need for data that can inform treatment, this review provides a brief description of newer publications focused on mania in older-age bipolar disorder (OABD), including epidemiology, diagnosis, and treatments. RECENT FINDINGS Age cutoffs to define OABD range from 50 to 65 years. OABD clinical presentation and course of illness is highly variable, often characterized by mood episode recurrence, medical comorbidity, cognitive deficits, and impaired functioning. There is little pharmacotherapy data on mania in OABD. Lithium and valproate have been tested in a single randomized controlled trial and there is data of more limited quality with other compounds. Treating OABD is challenging due to medical complexity, comorbidity, diminished tolerance to treatment, and a limited evidence base. More data is needed to keep pace with clinical demand.
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Ryan PB, Schuemie MJ, Ramcharran D, Stang PE. Atypical Antipsychotics and the Risks of Acute Kidney Injury and Related Outcomes Among Older Adults: A Replication Analysis and an Evaluation of Adapted Confounding Control Strategies. Drugs Aging 2017; 34:211-219. [PMID: 28124262 DOI: 10.1007/s40266-016-0430-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE A recently published analysis of population-based claims data from Ontario, Canada reported higher risks of acute kidney injury (AKI) and related outcomes among older adults who were new users of atypical antipsychotics (AAPs) compared with unexposed patients. In light of these findings, the objective of the current study was to further investigate the risks of AKI and related outcomes among older adults receiving AAPs. METHODS A replication of the previously published analysis was performed using the US Truven MarketScan Medicare Supplemental database (MDCR) among patients aged 65 years and older. Compared with non-users of AAPs, the study compared the risk of AKI and related outcomes with users of AAPs (quetiapine, risperidone, olanzapine, aripiprazole, or paliperidone) using a 1-to-1 propensity score matched analysis. In addition, we performed adapted analyses that: (1) included all covariates used to fit propensity score models in outcome models; and (2) required patients to have a diagnosis of schizophrenia, bipolar disorder, or major depression and a healthcare visit within 90 days prior to the index date. RESULTS AKI effect estimates [as odds ratios (ORs) with 95% confidence intervals (CIs)] were significantly elevated in our MDCR replication analyses (OR 1.45, 95% CI 1.32-1.60); however, in adapted analyses, associations were not significant (OR 0.91, 95% CI 0.78-1.07)). In analyses of AKI and related outcomes, results were mostly consistent between the previously published and the MDCR replication analyses. The primary change that attenuated associations in adapted analyses was the requirement for patients to have a mental health condition and a healthcare visit prior to the index date. CONCLUSIONS The MDCR analysis yielded similar results when the methodology of the previously published analysis was replicated, but, in adapted analyses, we did not find significantly higher risks of AKI and related outcomes. The contrast of results between our replication and adapted analyses may be due to the analytic approach used to compare patients (and potential confounding by indication). Further research is warranted to evaluate these associations, while also examining methods to account for differences in older adults who do and do not use these medications.
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Affiliation(s)
- Patrick B Ryan
- Janssen Research & Development, LLC, Global Research and Development Epidemiology, 1125 Trenton Harbourton Road, Rm K30205, Titusville, NJ, 08560, USA
| | - Martijn J Schuemie
- Janssen Research & Development, LLC, Global Research and Development Epidemiology, 1125 Trenton Harbourton Road, Rm K30205, Titusville, NJ, 08560, USA
| | - Darmendra Ramcharran
- Janssen Research & Development, LLC, Global Research and Development Epidemiology, 1125 Trenton Harbourton Road, Rm K30205, Titusville, NJ, 08560, USA.
| | - Paul E Stang
- Janssen Research & Development, LLC, Global Research and Development Epidemiology, 1125 Trenton Harbourton Road, Rm K30205, Titusville, NJ, 08560, USA
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14
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El-Saifi N, Jones C, Moyle W. Quetiapine adverse events in older adults in Australia. Australas J Ageing 2016; 35:281-284. [DOI: 10.1111/ajag.12347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Najwan El-Saifi
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
| | - Cindy Jones
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
- Centre for Health Practice Innovation; Griffith University; Brisbane Queensland Australia
| | - Wendy Moyle
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
- Centre for Health Practice Innovation; Griffith University; Brisbane Queensland Australia
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15
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El-Saifi N, Moyle W, Jones C, Tuffaha H. Quetiapine safety in older adults: a systematic literature review. J Clin Pharm Ther 2016; 41:7-18. [DOI: 10.1111/jcpt.12357] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 12/26/2015] [Indexed: 02/06/2023]
Affiliation(s)
- N. El-Saifi
- Menzies Health Institute Queensland; Griffith University; QLD Australia
| | - W. Moyle
- Menzies Health Institute Queensland; Griffith University; QLD Australia
| | - C. Jones
- Menzies Health Institute Queensland; Griffith University; QLD Australia
| | - H. Tuffaha
- Menzies Health Institute Queensland; Griffith University; QLD Australia
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16
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Forester BP, Ajilore O, Spino C, Lehmann S. Clinical Characteristics of Patients with Late Life Bipolar Disorder in the Community: Data from the NNDC Registry. Am J Geriatr Psychiatry 2015; 23:977-84. [PMID: 25670662 PMCID: PMC4503521 DOI: 10.1016/j.jagp.2015.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare clinical characteristics of older and younger patients with bipolar disorder enrolled in the United States' National Network of Depression Centers (NNDC) Clinical Care Registry (CCR). DESIGN Multicenter, de-identified naturalistic data from the National NNDC's CCR for all patients with a diagnosis of bipolar disorder who were enrolled in the registry as of April 25, 2013. PARTICIPANTS Community-dwelling patients (N = 218), ages 18 years or older, with bipolar disorder diagnosis recruited by NNDC-affiliated medical centers to participate in the NNDC CCR. Subjects aged 55 years or older were compared with subjects younger than age 55 years on clinical measures. MEASUREMENTS Patient Health Questionnaire; Quick Inventory of Depressive Symptomatology - Self-Report; Altman Self-Rating Mania Scale; Work and Social Adjustment Scale; Frequency and Intensity of Burden of Side Effects Rating; and the Self-Administered Comorbidity Questionnaire. RESULTS A greater percentage of older patients were prescribed antidepressant medications (71.9% versus 50.0%), and the younger cohort had significantly more psychostimulant use (16.7% versus 0%). Younger patients endorsed significantly more depressive symptoms compared with older patients. The mean number of psychotropic medications was not different in both older and younger patients with bipolar disorder. There was no statistically significant difference in frequency, intensity, or burden of psychotropic medication side effects as measured by the Frequency and Intensity of Burden of Side Effects Rating. CONCLUSION Findings of higher antidepressant use rates in the older cohort, combined with lower depression symptom severity and a similar degree of manic symptoms, suggests the possibility that older adults with bipolar disorder may have improved antidepressant efficacy and lower switch rates into manic or mixed states compared with younger cohorts. Ongoing data collection by the NNDC CCR will add to current knowledge to inform the care of older patients with bipolar disorder by providing multi-site data regarding phenomenology, treatment response, and longitudinal course of late life bipolar disorder in community settings.
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Coma After Quetiapine Fumarate Intentional Overdose in a 71-year-old Man: A Case Report. DRUG SAFETY - CASE REPORTS 2015; 2:3. [PMID: 27747715 PMCID: PMC4982457 DOI: 10.1007/s40800-015-0005-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 71-year-old man developed coma with severe respiratory failure, hypotension, and tachycardia induced by the intentional ingestion of quetiapine fumarate extended release (XR) 20 g. At the time, he had been treated for bipolar depression with venlafaxine 75 mg/day, lamotrigine 100 mg/day, pregabalin 75 mg/day, and quetiapine XR 400 mg/day for approximately 1 year. Comorbidities were hypertension treated with metoprolol, diabetes mellitus type 2 treated with metformin, and benign prostatic hyperplasia treated with silodosin. In the emergency room, about 4 h after ingestion of quetiapine fumarate XR, the presenting symptomatology was characterized by coma (Glasgow Coma Scale score 3), hypotension (blood pressure [BP] 90/60 mmHg), tachycardia (electrocardiogram [ECG] showed sinus tachycardia with heart rate 120 beats per minute and a QTc of 499 ms). A gastric lavage was performed and activated charcoal 50 g and magnesium sulfate 30 g was administered. About 6 h after ingestion, he developed marked desaturation and underwent mechanical ventilation; 13 h after ingestion, a severe hypotensive episode followed (BP 70/40), which was treated with an infusion of ringer lactate 500 cc. On the 3rd day after intentional overdose, an episode of agitation occurred; 4 days after ingestion, the quetiapine plasma level was found to be 42 ng/ml (within therapeutic range). At 5 days after ingestion, the patient developed septicemia caused by staphylococci (probably originating from the central vein catheter), which was treated with antibiotic therapy. On days 10 and 18 after the suicide attempt, two episodes of paroxysmal supraventricular tachycardia (PSVT) occurred and were successfully treated with intravenous adenosine triphosphate. The patient recovered completely without residual symptoms. In line with literature data, in this case report, symptoms of quetiapine overdose were tachycardia, agitation, hypotension, QT interval prolongation, and coma. A causal relationship between PSVT and quetiapine intoxication seems quite unlikely due to the drug level.
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18
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Abstract
The metabolic side effects of atypical antipsychotics (AAPs) have been widely studied in younger populations, but research investigating these sequelae in the elderly is lacking. This article reviews the available literature examining the use of AAPs in the elderly, evaluating their association with weight gain and changes in blood glucose and lipid parameters. We find a relative paucity of studies in this area; while some data highlight significant, collective changes in metabolic parameters, the majority suggests an apparent low vulnerability to these side effects. We conclude that the risk and clinical implications of unfavorable metabolic changes in the elderly being treated with AAP medications remain largely undetermined, and we caution against drawing firm conclusions based on the available data. The conflicting evidence leaves us recommending that metabolic monitoring be implemented, with regular follow-up as advocated in other populations.
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19
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Current Concepts Relative to the Appropriate Use of Antipsychotics in the Elderly. CURRENT GERIATRICS REPORTS 2014. [DOI: 10.1007/s13670-014-0097-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Gareri P, Segura-García C, Manfredi VGL, Bruni A, Ciambrone P, Cerminara G, De Sarro G, De Fazio P. Use of atypical antipsychotics in the elderly: a clinical review. Clin Interv Aging 2014; 9:1363-73. [PMID: 25170260 PMCID: PMC4144926 DOI: 10.2147/cia.s63942] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The use of atypical antipsychotic drugs in the elderly has become wider and wider in recent years; in fact, these agents have novel receptor binding profiles, good efficacy with regard to negative symptoms, and reduced extrapyramidal symptoms. However, in recent years, the use of both conventional and atypical antipsychotics has been widely debated for concerns about their safety in elderly patients affected with dementia and the possible risks for stroke and sudden death. A MEDLINE search was made using the words elderly, atypical antipsychotics, use, schizophrenia, psychosis, mood disorders, dementia, behavioral disorders, and adverse events. Some personal studies were also considered. This paper reports the receptor binding profiles and the main mechanism of action of these drugs, together with their main use in psychiatry and the possible adverse events in elderly people.
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Affiliation(s)
- Pietro Gareri
- Elderly Health Care, Azienda Sanitaria Provinciale Catanzaro, Catanzaro, Italy
| | | | | | - Antonella Bruni
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | - Paola Ciambrone
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | - Gregorio Cerminara
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | | | - Pasquale De Fazio
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
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21
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Bak M, Fransen A, Janssen J, van Os J, Drukker M. Almost all antipsychotics result in weight gain: a meta-analysis. PLoS One 2014; 9:e94112. [PMID: 24763306 PMCID: PMC3998960 DOI: 10.1371/journal.pone.0094112] [Citation(s) in RCA: 308] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 03/12/2014] [Indexed: 02/08/2023] Open
Abstract
Introduction Antipsychotics (AP) induce weight gain. However, reviews and meta-analyses generally are restricted to second generation antipsychotics (SGA) and do not stratify for duration of AP use. It is hypothesised that patients gain more weight if duration of AP use is longer. Method A meta-analysis was conducted of clinical trials of AP that reported weight change. Outcome measures were body weight change, change in BMI and clinically relevant weight change (7% weight gain or loss). Duration of AP-use was stratified as follows: ≤6 weeks, 6–16 weeks, 16–38 weeks and >38 weeks. Forest plots stratified by AP as well as by duration of use were generated and results were summarised in figures. Results 307 articles met inclusion criteria. The majority were AP switch studies. Almost all AP showed a degree of weight gain after prolonged use, except for amisulpride, aripiprazole and ziprasidone, for which prolonged exposure resulted in negligible weight change. The level of weight gain per AP varied from discrete to severe. Contrary to expectations, switch of AP did not result in weight loss for amisulpride, aripiprazole or ziprasidone. In AP-naive patients, weight gain was much more pronounced for all AP. Conclusion Given prolonged exposure, virtually all AP are associated with weight gain. The rational of switching AP to achieve weight reduction may be overrated. In AP-naive patients, weight gain is more pronounced.
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Affiliation(s)
- Maarten Bak
- Maastricht University Medical Centre, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht, The Netherlands
- * E-mail:
| | - Annemarie Fransen
- Maxima Medical Centre Dep. of gynaecology, Veldhoven, The Netherlands
| | - Jouke Janssen
- Maastricht University Medical Centre, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht, The Netherlands
| | - Jim van Os
- Maastricht University Medical Centre, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht, The Netherlands
- King's College London, King's Health Partners, Department of Psychosis Studies, Institute of Psychiatry, London, United Kingdom
| | - Marjan Drukker
- Maastricht University Medical Centre, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht, The Netherlands
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22
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Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, O'Donovan C, Macqueen G, McIntyre RS, Sharma V, Ravindran A, Young LT, Milev R, Bond DJ, Frey BN, Goldstein BI, Lafer B, Birmaher B, Ha K, Nolen WA, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord 2013; 15:1-44. [PMID: 23237061 DOI: 10.1111/bdi.12025] [Citation(s) in RCA: 540] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.
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Affiliation(s)
- Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
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Allan CL, Ebmeier KP. Prophylaxis and treatment of bipolar disorder in older adults. J Psychiatry Neurosci 2012; 37:E7-8. [PMID: 22709480 PMCID: PMC3380100 DOI: 10.1503/jpn.120019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Charlotte L Allan
- Department of Psychiatry University of Oxford Warneford Hospital Oxford, United Kingdom
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Malhi GS, Bargh DM, Cashman E, Frye MA, Gitlin M. The clinical management of bipolar disorder complexity using a stratified model. Bipolar Disord 2012; 14 Suppl 2:66-89. [PMID: 22510037 DOI: 10.1111/j.1399-5618.2012.00993.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To provide practical and clinically meaningful treatment recommendations that amalgamate clinical and research considerations for several common, and as yet understudied, bipolar disorder complex presentations, within the framework of a proposed stratified model. METHODS A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Web of Science) using key words (e.g., bipolar disorder, anxiety, rapid cycling, and subsyndromal). All relevant randomised controlled trials were examined, in addition to review papers, meta-analyses, and book chapters known to the authors. The findings formed the basis of the treatment recommendations within this paper. RESULTS In light of the many broad presentations of bipolar disorder, a stratified model of bipolar disorder complexity was developed to facilitate consideration of the myriad of complexities that can occur during the longitudinal course of illness and the appropriate selection of treatment. Evidence-based treatment recommendations are provided for the following bipolar disorder presentations: bipolar II disorder, subsyndromal symptoms, mixed states, rapid cycling, comorbid anxiety, comorbid substance abuse, and for the following special populations: young, elderly, and bipolar disorder around the time of pregnancy and birth. In addition, some key strategies for countering treatment non-response and alternative medication recommendations are provided. CONCLUSIONS Treatment recommendations for the more challenging presentations of bipolar disorder have historically received less attention, despite their prevalence. This review acknowledges the weaknesses in the current evidence base on which treatment recommendations are generally formulated, and additionally emphasises the need for high-quality research in this area. The stratified model provides a means for conceptualizing the complexity of many bipolar disorder presentations and considering their management.
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Affiliation(s)
- Gin S Malhi
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, New South Wales, Australia.
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Bhalerao S, Seyfried LS, Kim HM, Chiang C, Kavanagh J, Kales HC. Mortality risk with the use of atypical antipsychotics in later-life bipolar disorder. J Geriatr Psychiatry Neurol 2012; 25:29-36. [PMID: 22467844 PMCID: PMC4216676 DOI: 10.1177/0891988712436687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION In recent years, concerns about the use of antipsychotic medications in dementia have grown. There is limited data on mortality risk of atypical antipsychotics for other psychiatric disorders of later life such as bipolar disorder. METHODS Data were derived from the national Department of Veterans Affairs registries for older patients with bipolar disorder (≥65 years) with a new start of an atypical antipsychotic (risperidone, olanzapine, or quetiapine) or valproic acid and derivatives during fiscal years 2001-2008. Six-month mortality rates were compared for individual drug groups. RESULTS The sample included 4717 patients. The risperidone cohort had the highest mortality rate (11.8 per 100 person-years) with the quetiapine and valproic acid cohorts having the lowest (5.3 and 4.6 per 100 person-years, respectively). Various methods to adjust for baseline differences including propensity models showed similar patterns. CONCLUSIONS Among older patients with bipolar disorder, there may be differences in mortality risks among individual antipsychotic agents.
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Affiliation(s)
- Sachin Bhalerao
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Lisa S. Seyfried
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Hyungjin Myra Kim
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Department of Veterans Affairs, Center for Clinical Management Research (CCMR), Ann Arbor, Michigan,Serious Mental Illness Treatment, Resource, and Evaluation Center (SMITREC), Ann Arbor, Michigan,Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, Michigan
| | - Claire Chiang
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Department of Veterans Affairs, Center for Clinical Management Research (CCMR), Ann Arbor, Michigan,Serious Mental Illness Treatment, Resource, and Evaluation Center (SMITREC), Ann Arbor, Michigan
| | - Janet Kavanagh
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Helen C. Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Department of Veterans Affairs, Center for Clinical Management Research (CCMR), Ann Arbor, Michigan,Serious Mental Illness Treatment, Resource, and Evaluation Center (SMITREC), Ann Arbor, Michigan
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Sajatovic M, Al Jurdi R, Gildengers A, Greenberg RL, Tenhave T, Bruce ML, Mulsant B, Young RC. Depression symptom ratings in geriatric patients with bipolar mania. Int J Geriatr Psychiatry 2011; 26:1201-8. [PMID: 21360754 PMCID: PMC3651791 DOI: 10.1002/gps.2664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 10/26/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Given the paucity of information available regarding standardized ratings of depression symptoms in bipolar manic states, and in particular those in older adults, we explored depression ratings in symptomatic participants in a multicenter study of treatment of bipolar I disorder in late life. METHODS Baseline data was obtained from the first 100 patients enrolled in an NIMH-funded, 9-week, randomized, double-blind RCT comparing treatment with lithium or valproate in patients of age 60 years and older with Type I Bipolar mania or hypomania. This multi-site study was conducted at six academic medical centers in the United States and enrolled inpatients and outpatients with a total Young Mania Rating Scale (YMRS) score of 18 or greater. Depressive symptoms were evaluated with the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). The criterion for at least moderate bipolar depressive symptoms was the European College of Neuropsychopharmacology (ECNP) Consensus Meeting definition of HAM-D 17 total score >20. RESULTS Eleven percent of patients had mixed symptoms defined by depression scale severity according to ECNP criterion. In the overall sample, total scores on the two depression scales were highly correlated. Total YMRS scores of this mixed symptom group were similar to the remainder of the sample. CONCLUSIONS These preliminary findings suggest that moderate to severe depressive symptoms occur in about one in ten bipolar manic elders. Future studies are needed to further evaluate symptom profiles, clinical correlates, and treatments for bipolar older adults with combined manic and depressive symptoms.
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Affiliation(s)
- Martha Sajatovic
- Department of Psychiatry, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Rayan Al Jurdi
- Department of Psychiatry, The Menninger Department of Psychiatry at Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Ariel Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA
| | | | - Thomas Tenhave
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Martha L. Bruce
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY
| | - Benoit Mulsant
- Geriatric Mental Health Program, Center for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Robert C. Young
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY
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Abstract
Because the elderly are the fastest growing segment of the population, the number of older adults with bipolar disorder is increasing. Geriatric bipolar disorder is relatively rare, with an estimated lifetime prevalence of 0.5% to 1%, although approximately 4% to 17% of older patients in clinical psychiatric settings have bipolar disorder. Bipolar elders are disproportionately affected by medical burden. Given the complex nature of this disorder, comorbidity, and behavioral disturbances, various interventions may be indicated, including pharmacotherapies, electroconvulsive therapy, psychotherapies, and integrated care models. Additional research is needed to better understand the epidemiology, phenomenology, and treatment of geriatric bipolar disorder.
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Affiliation(s)
- Martha Sajatovic
- Department of Psychiatry, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Shulman KI. Lithium for older adults with bipolar disorder: Should it still be considered a first-line agent? Drugs Aging 2010; 27:607-15. [PMID: 20658789 DOI: 10.2165/11537700-000000000-00000] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of lithium carbonate for the treatment of bipolar disorder in older adults is decreasing at a significant rate. This change in prescription pattern is occurring at a time when all evidence-based treatment guidelines and systematic reviews still recommend lithium as a first-line treatment for bipolar disorder. Despite having the strongest evidence base for effectiveness, lithium does pose significant concerns in the older population, including the risk of drug interactions that cause toxicity associated with decreased creatinine clearance. The evidence for lithium's impact on chronic renal disease is still controversial and is reviewed in this article. Mixed evidence exists regarding the impact of lithium on suicide risk, although there is a consensus that it does have protective properties through its mood-stabilizing effect. Because of the very limited research base regarding the use of lithium in old age, guidelines for dosing and maintenance of serum concentrations are not well established, and this may be leading to increased episodes of lithium toxicity. At the same time that these legitimate concerns about lithium are being highlighted, evidence has accumulated that suggests that lithium may have neuroprotective properties. Its action of inhibiting the enzyme glycogen synthase kinase-3 may be responsible in part for a decrease in the induction of amyloid beta peptide and hyperphosphorylated tau protein, which have been implicated in the development of Alzheimer's disease. Very little evidence supports use of alternatives to lithium such as other mood-stabilizing agents, including atypical antipsychotics, in older adults. Thus, before we abandon lithium as a first-line agent, we should ensure that the guidelines for lithium treatment are safe, practical and effective. Newer agents must be appropriately tested in older adults before replacing this longstanding first-line treatment for bipolar disorder.
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Affiliation(s)
- Kenneth I Shulman
- Department of Psychiatry, University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
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Vasudev A, Thomas A. 'Bipolar disorder' in the elderly: what's in a name? Maturitas 2010; 66:231-5. [PMID: 20307944 DOI: 10.1016/j.maturitas.2010.02.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 02/22/2010] [Accepted: 02/22/2010] [Indexed: 01/01/2023]
Abstract
Bipolar disorder is a chronic disorder of mood which leads to episodes of either elevated mood or depression in a sizable number of adults in the community (1%). Though the prevalence rates in the elderly are lower in the community (up to 0.1%), there is significantly higher morbidity in protected environments like care homes and hospital settings where prevalence rates may be as high as 10%. Bipolar disorder in the elderly is probably heterogenous and its etiopathogenesis is complex. Bipolar disorder may be divided into two distinct subtypes, the late onset bipolar (LOB) and the early onset bipolar (EOB) groups. LOB patients tend to have a milder illness in terms of manic severity but they have higher medical and neurological burden. They also have lower familial burden of bipolar illness as compared to EOB patients. There is an increased risk of dementia and stroke in patients with late life bipolar disorder (and there may be a protective effect of lithium in preventing dementia). White matter changes, as seen by increased white matter hyperintensities on neuroimaging, are also increased, providing further evidence of cerebrovascular disease. Treatment of late life bipolar is currently based on guidelines drawn up for younger bipolar disorder patients. Good quality intervention studies are needed to estimate the possible protective effect of cognitive enhancers and/or vascular prevention strategies. This review suggests that late life bipolar disorder, particularly late onset bipolar disorder, is probably a distinct diagnostic entity compared to the younger bipolar patients as it has a different presentation, etiology and hence perhaps needs different treatment strategies.
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Affiliation(s)
- Akshya Vasudev
- Institute for Ageing and Health, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
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Young RC, Schulberg HC, Gildengers AG, Sajatovic M, Mulsant BH, Gyulai L, Beyer J, Marangell L, Kunik M, Ten Have T, Bruce ML, Gur R, Marino P, Evans JD, Reynolds CF, Alexopoulos GS. Conceptual and methodological issues in designing a randomized, controlled treatment trial for geriatric bipolar disorder: GERI-BD. Bipolar Disord 2010; 12:56-67. [PMID: 20148867 PMCID: PMC3039416 DOI: 10.1111/j.1399-5618.2009.00779.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This report considers the conceptual and methodological concerns confronting clinical investigators seeking to generate knowledge regarding the tolerability and benefits of pharmacotherapy in geriatric bipolar disorder (BD) patients. METHOD There is continuing need for evidence-based guidelines derived from randomized controlled trials that will enhance drug treatment of geriatric BD patients. Therefore, we present the complex conceptual and methodological choices encountered in designing a multisite clinical trial and the decisions reached by the investigators with the intention that study findings be pertinent to, and can facilitate, routine treatment decisions. RESULTS Guided by a literature review and input from peers, the tolerability and antimanic effects of lithium and valproate were judged to be the key mood stabilizers to investigate with regard to treating bipolar I disorder manic, mixed, and hypomanic states. The patient selection criteria are intended to generate a sample that not only experiences common treatment needs but also represents the variety of older patients seen in university-based clinical settings. The clinical protocol guides titration of lithium and valproate to target serum concentrations, with lower levels allowed when necessitated by limited tolerability. The protocol emphasizes initial monotherapy. However, augmentation with risperidone is permitted after three weeks when indicated by operational criteria. CONCLUSIONS A randomized, controlled trial that both investigates commonly prescribed mood stabilizers and maximizes patient participation can meaningfully address high-priority clinical concerns directly relevant to the routine pharmacologic treatment of geriatric BD patients.
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Affiliation(s)
- Robert C Young
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, NY 10605, USA.
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Affiliation(s)
- Laszlo Gyulai
- Department of Psychiatry, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Robert C. Young
- Weill Medical College of Cornell University, Institute of Geriatric Psychiatry, White Plains, NY, USA
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