The NYSPA Report: Mental Health and the Geriatric Population

I am pleased to share with you an interview we conducted with Dilip Jeste, MD, Professor, Department of Psychiatry at the University of California, San Diego. He is also a past President of the American Psychiatric Association and a member of the Brain & Behavior Research Foundation Scientific Council.

Q: What made you enter the psychiatric field, and why do you particularly focus on late-life mental health issues?

A: As a teenager growing up in India, I was fascinated by Freud’s books regarding interpretation of dreams and everyday errors of life. I felt that these books were similar to detective stories and murder mysteries—except that they sought to uncover secrets of the mind. I decided to go to medical school in order to become a psychiatrist—which was considered, to put it mildly, “a very unusual choice” by others. My goal was to study the science of the mind.

My interest in aging began much later and was driven by the fact that the population of the world is aging. The number of people over 65 in the U.S. will double in the next two decades. I also found on reading the relevant literature that the numbers of older people with mental illness will rise even faster than those in the general population. Therefore, this seemed like an exciting area for new studies.

Q: What are the particular challenges of late-life mental health?

A: The challenges include deteriorating physical health, neurocognitive impairment associated with aging, financial and psychosocial stressors—and importantly, the stigma of aging. Older people with mental illness have to fight the dual stigma of aging and mental illness. They don’t have resources to advocate for themselves, and as a result, they constitute one of the most disenfranchised groups in society. Also, there is far less research on older people than on younger adults. The tendency is to transfer findings in younger adults to older ones; yet, this is inappropriate because of various psychobiosocial differences between the two groups as well as increasing heterogeneity with aging.

Q: You have done extensive research on late-life psychosis and its treatment. What are the challenges in this area and how is it different from other psychosis (early-onset or other)?

A: Late-life psychosis includes late-onset psychosis as well as persistence (or recurrence) of psychosis that first manifested earlier in life. The amount of published research on psychosis in late life is miniscule compared to that in younger people. Whereas schizophrenia and bipolar disorder are the two most important causes of psychosis earlier in life, the etiology becomes more complex and varied in later life. For example, psychosis associated with Alzheimer’s disease and other dementias is more or less restricted to older adults. The number of people with psychosis associated with dementia is comparable to the number of people with schizophrenia across all age groups.

There is an interesting gender difference between early-onset and late-onset schizophrenia. Whereas males with schizophrenia markedly outnumber their female counterparts until about 30 years of age, the gender proportions reverse after age 45, possibly hinting at a role of hormones such as estrogens in late-onset schizophrenia.

Q: You are a widely recognized expert in the field of geriatric mental illness and received a Brain and Behavioral Research Foundation (BBRF) Distinguished Investigator Grant. What did the BBRF Grant enable you to do?

A: My younger colleague Elizabeth Twamley, PhD, and I initiated a study of work on rehabilitation in middle-aged and older adults with schizophrenia. The conventional wisdom is that persons with schizophrenia, especially the older ones, would be incapable of gainful employment. Yet, we found that, with appropriate support and guidance, many middle-aged and older people with schizophrenia not only could be employed, but they stayed on the jobs, and had an improvement in their functioning as well as quality of life. The critical element in making this possible was societal support.

Q: Please highlight the discovery you have made that you are most proud of and tell us why.

A: In recent years, I have been working on successful psychosocial aging. I have found that, even in people with serious mental illnesses such as schizophrenia, the functioning improves with age. People who have suffered from a mental illness for decades learn from their experience slowly but surely. Many of them develop insight, begin to differentiate psychopathology (delusions, hallucinations) from normal experience, become more adherent to their treatment in order to avoid relapses, stop using substances of abuse and become happier. While some of this may be due to survivor cohort effect (i.e., the sickest individuals die young and do not live into older age), that is not the whole story. We have been following people with schizophrenia for the past 25 years, and have commonly noticed progressive improvement of this type. Whether one may call it recovery or sustained remission, the improvement with aging is often remarkable. With better treatments and greater social support, this should become a norm.

Q: What is the most important question you would like to answer about the aging brain and late-life mental health?

A: While most people associate aging with degeneration, deterioration, disability, disease, and then death, I am fascinated by psychoneuroplasticity of aging. Aging is often associated with increasing wisdom through better social decision making. The most important questions for me relate to the underlying neurobiology and the behavioral and environmental factors that promote the neuroplasticity of aging.

Q: What else would you like to say about late-life mental health?

A: Older people (with or without mental illness) are an invaluable resource for the society in terms of their wealth of experience and wisdom. It is unfortunate that they are usually considered a drain on the society. The more we learn about regeneration of an aging brain and about how to promote and use the resulting wisdom, the better the society will be.

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