Geriatric Bipolar Disorder - Epidemiology, Clinical Features, Assessment, and Diagnosis PDF

Geriatric bipolar disorder: Epidemiology, clinical features, assessment,...
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Geriatric bipolar disorder: Epidemiology, clinical features, assessment, and diagnosis Authors Martha Sajatovic, MD Peijun Chen, MD, MPH, PhD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Jun 14, 2013. INTRODUCTION The clinical features and treatment of older bipolar patients differ from those of younger patients [1]. Up to 25 percent of all bipolar patients are elderly [2], and the absolute number of geriatric bipolar patients is expected to increase as the worlds population ages over the next several decades [3,4]. This topic reviews the epidemiology, pathogenesis, clinical features, assessment, diagnosis, and differential diagnosis of geriatric bipolar disorder. The treatment and prognosis of geriatric bipolar disorder are discussed separately. (See "Geriatric bipolar disorder: Acute treatment" and "Geriatric bipolar disorder: Maintenance treatment and prognosis".) DEFINITION The minimum age used to define geriatric bipolar disorder is generally 60 years [5]. However, some authorities use an age cut-off of 50, 55, or 65 years [6]. Geriatric bipolar disorder includes both aging patients whose mood disorder presented earlier in life, and patients whose mood disorder presents for the first time in later life [1,7]. EPIDEMIOLOGY The prevalence of geriatric bipolar disorder varies depending upon the setting and study sample. The estimated one-year prevalence of bipolar disorder in the United States general population aged 65 years or older is 0.1 percent [8]; the estimated lifetime rate for individuals aged 60 years or older is 1 percent [9]. The prevalence of geriatric bipolar disorder is higher in clinical settings: Nursing home residents 3 percent [10] Psychiatric outpatients 6 to 7 percent [6,11] Psychiatric inpatients 7 to 10 percent [6] General hospital emergency department 17 percent [6] Bipolar patients 7 to 25 percent [2,12-14] Among geriatric bipolar patients treated in clinical settings, approximately 70 to 95 percent represent cases with onset prior to age 50 years that has persisted into later life [13,15]. Geriatric bipolar patients are predominantly female; a review of 17 studies found that approximately 69 percent of late-life bipolar patients were women [6]. By contrast, a cross-national epidemiologic study of mostly younger bipolar adults found that the ratio of females to males was approximately 1:1 [16]. PATHOGENESIS It is not known what causes bipolar disorder. However, the etiology of late-onset geriatric bipolar disorder (age 50 years or older) may possibly differ from earlier-onset bipolar disorder that has persisted into later life [17]. This is suggested by observations that cerebrovascular pathology occurs in more late-onset geriatric bipolar patients [6]. As an example, one neuroimaging study detected cerebrovascular lesions (with no associated focal neurologic symptoms) in significantly more late-onset geriatric bipolar patients (N = 20) than age-matched, earlier-onset patients (N = 20) (65 versus 25 percent) [18]. Mood episodes that occur in geriatric bipolar patients may possibly be due in part to negative life events such as marital discord as well as changes in family role, residence, employment, and finances [17,19]. One study found that older bipolar patients had more than twice as many stressful life events compared with age-matched controls [20]. Section Editors Paul Keck, MD Kenneth E Schmader, MD Deputy Editor David Solomon, MD
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CLINICAL FEATURES Bipolar disorder is characterized by episodes of major depression (table 1), mania (table 2), and hypomania (table 3), as well as mixed episodes (major depression concurrent with mania) [21]. However, the clinical features of bipolar disorder are different for older and younger patients in that [1,22-25]: Cognitive impairment is more common and severe in geriatric patients Comorbid general medical illnesses are more common in older patients Excessive sexual interest and behavior during manic or hypomanic episodes appear to be less common in older patients Comorbid anxiety and substance use disorders are less common in geriatric patients The clinical features of late-onset geriatric bipolar disorder (age 50 years or older) and earlier-onset bipolar disorder that has persisted into later life appear to be similar [13,26]. Cognitive impairment Cognitive deficits occur in approximately 40 to 50 percent of euthymic, geriatric bipolar patients [27,28]. Comparisons with age-matched healthy controls show that late-life bipolar patients have deficits in [27,29-31]: Executive functions Verbal memory Psychomotor speed Global cognitive functioning These deficits are similar to the types of cognitive deficits that are observed in euthymic, younger adult bipolar patients [32,33]. However, neuropsychologic impairment occurs more frequently and is more severe in geriatric bipolar patients than younger patients [23,24]. Patients with geriatric bipolar disorder may develop dementia at a higher than expected rate [34,35]. A study of 4668 veterans with geriatric bipolar disorder found that dementia was present in 5 percent [36]. A review of five studies found that as many as 25 to 30 percent of inpatients with late-life bipolar disorder were also demented [6]. Comorbidity Comorbidity is common in late-life bipolar disorder [6,17]. A study of approximately 300 geriatric patients hospitalized for bipolar disorder found that the median number of comorbid disorders was seven [37]. Much of the comorbidity is accounted for by general medical illnesses. General medical disorders General medical conditions are significantly more common in geriatric bipolar patients than younger patients [1,38]. One study of 54 late-life bipolar patients found that morbidity affected a mean average of six organ systems [39]. The most common illnesses are [39,40]: Hypertension 80 percent of geriatric bipolar patients Hyperlipidemia 75 percent Diabetes 32 percent Hypothyroidism 22 percent Coronary heart disease 19 percent Asthma 6 percent These general medical illnesses are discussed separately. (See "Overview of hypertension in adults" and "Measurement of serum lipids and lipoproteins" and "Classification of diabetes mellitus and genetic diabetic syndromes" and "Diagnosis of and screening for hypothyroidism in nonpregnant adults" and "Screening for coronary heart disease" and "Diagnosis and management of asthma in older adults".) Psychiatric disorders Substance use disorders and anxiety disorders are the two most common psychiatric comorbidities in geriatric bipolar disorder [6,11,22]. However, the prevalence of substance use and anxiety disorders is significantly less in geriatric bipolar patients than younger patients [22,41]. Substance use disorders Substance use disorders occur in approximately 10 to 40 percent of geriatric bipolar patients, depending upon the study [11,22,36,41]. By contrast, comorbid substance use disorders occur in approximately 60 percent or more of younger bipolar patients [42]. Substance use disorders are discussed separately. (See "Substance use disorders: Principles for recognition and assessment in general medical care".) Anxiety disorders Anxiety disorders occur in about 10 percent of patients with geriatric bipolar disorder:
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A study of 16,330 veterans with late-life bipolar disorder found that 10 percent had one or more anxiety disorders, including [36]: Generalized anxiety disorder Panic disorder with or without agoraphobia Social anxiety disorder Specific phobia Obsessive compulsive disorder Anxiety disorder not otherwise specified A community survey found that in 84 geriatric bipolar patients, panic disorder occurred in 12 percent and generalized anxiety disorder in 10 percent, which was significantly greater than the prevalence in 8121 elderly controls [22]. These anxiety disorders are discussed separately. (See "Generalized anxiety disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Panic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Social anxiety disorder: Epidemiology, clinical manifestations, and diagnosis" and "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".) ASSESSMENT The initial clinical evaluation of elderly patients with a possible diagnosis of bipolar disorder includes a psychiatric history and mental status examination, with emphasis upon depressive (table 1), manic (table 2), and hypomanic symptoms (table 3), as well as symptoms of substance abuse disorders and anxiety disorders [21,43,44]. Patients presenting with major depression may not recall prior episodes of mania or hypomania, especially if these last occurred several years or decades in the past, were marked by irritability rather than euphoria, or consisted of post-partum mood states. Interviewing family members can help elicit a past history of mania or hypomania. In addition, the mental status examination should address cognition. We often include the Mini-Mental State Examination, which is a brief test administered by the clinician that evaluates orientation, recall, attention, calculation, language manipulation, and constructional praxis [45]. Use of the Mini-Mental State Examination is discussed separately. (See "Evaluation of cognitive impairment and dementia", section on 'Mini-Mental State Examination'.) The clinician should also obtain a general medical history and physical examination, as well as laboratory tests and imaging studies that are guided by the history and examination [43,44,46]. The medical work-up should emphasize general medical disorders commonly observed in geriatric bipolar patients, which are discussed separately. (See 'General medical disorders' above.) The initial evaluation of elderly patients with a possible diagnosis of bipolar disorder often occurs in a medical or psychiatric emergency department when the patient presents with reckless behavior, suicidal ideation or behavior, psychosis, functional decline (eg, impaired activities of daily living and social isolation), or exacerbation of a general medical illness. Screening Self-report screening instruments can help make the diagnosis and save interviewer time, but are more likely to yield false positives than clinician-administered instruments. No screening instruments have been specifically developed for geriatric bipolar disorder. However, self-report screening instruments for bipolar disorder that have been evaluated in mixed-age populations and are easy to use include the: Mood Disorder Questionnaire This 15-item instrument screens for episodes of mania and hypomania (table 4) [47]. The psychometric properties are good, including a sensitivity of 0.63 to 0.76 and a specificity of 0.85 to 0.90 in psychiatric outpatient clinics [48], and a sensitivity of 0.58 and a specificity of 0.93 in a family medicine clinic [49]. The Mood Disorder Questionnaire does not generate a diagnosis of mania or hypomania; thus, patients who screen positive require a clinical interview to make the diagnosis.
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Patient Health Questionnaire - 9 Item (PHQ-9) This 9-item instrument screens for episodes of major depression, provides a diagnosis, and has good psychometric properties (table 5) [50]. The PHQ-9 is discussed separately. (See "Using scales to monitor symptoms and treat depression (measurement based care)", section on 'Patient Health Questionnaire - Nine Item'.) DIAGNOSIS There are three subtypes of bipolar disorder that can be diagnosed, depending upon the mood symptoms and episodes that have occurred [21]: Bipolar I Bipolar II Bipolar disorder not otherwise specified The diagnostic criteria for each subtype of bipolar disorder are identical for geriatric and younger patients. Diagnosis of bipolar disorder is discussed separately. (See "Bipolar disorder in adults: Assessment and diagnosis", section on 'Diagnosis'.) DIFFERENTIAL DIAGNOSIS New-onset manic symptoms in geriatric patients may be due to a general medical condition rather than bipolar disorder [51,52]. In addition, the differential diagnosis of bipolar disorder includes schizophrenia, schizoaffective disorder, unipolar major depression, and substance use disorder, which is discussed separately. (See "Bipolar disorder in adults: Assessment and diagnosis", section on 'Differential diagnosis'.) General medical conditions Manic or major depressive episodes that are due to the direct physiologic effects of a general medical condition are distinguished from bipolar disorder and instead classified as a mood disorder due to a general medical condition in the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) [21]. The term organic bipolar affective disorder is used in the World Health Organization's International Classification of Diseases-10th Revision (ICD-10) for mood episodes secondary to medical conditions [53]. The assessment (general medical history, physical examination, laboratory tests, and imaging studies) is critical for determining whether a general medical condition is present and etiologically related to the patients mood episode. Among the many potential etiologies for geriatric mania secondary to a general medical condition, the most common include [7,51,54,55]: Multiple sclerosis Multiple sclerosis is characterized by episodes of central nervous system dysfunction that commonly include sensory symptoms (eg, paresthesias, pain, or optic neuritis) and motor symptoms (eg, paraparesis). The clinical findings are augmented with neuroimaging and laboratory studies to diagnose the disorder. (See "Epidemiology and clinical features of multiple sclerosis in adults".) Stroke Ischemia or hemorrhage results in acute neurologic injury and can cause focal loss of brain function. Strokes in the right orbital frontal lobe, temporal lobe, basal ganglia, or thalamus have been associated with mania. Stroke is diagnosed based upon the results of the history, neurologic exam, and neuroimaging studies. (See "Overview of the evaluation of stroke".) Brain tumors Brain tumors can present with generalized symptoms (eg, headache, seizures, or nausea) or focal neurologic symptoms (eg, weakness or sensory loss). Neuroradiologic imaging is the major diagnostic modality in the evaluation of brain tumors. (See "Clinical presentation and diagnosis of brain tumors".) Mild traumatic brain injury due to falls Concussion is characterized by confusion and amnesia, often without preceding loss of consciousness. Assessment focuses upon cognition; neuroimaging is usually normal. (See "Concussion and mild traumatic brain injury".) Systemic infection with the human immunodeficiency virus (HIV) Patients infected with HIV can present with an ill-defined febrile illness or aseptic meningitis in the context of high-risk sexual behavior or injection drug abuse. Rash, mucocutaneous ulcers, and lymphadenopathy may be found on physical examination, and serologic testing is positive for HIV antibodies. (See "Acute and early HIV infection: Treatment".) Hyperthyroidism Hyperthyroidism characteristically includes palpitations, heat intolerance, increased perspiration, dyspnea on exertion, and weight loss despite a normal appetite. Physical examination is
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notable for tachycardia, lid retraction and lid lag, tremor, and enlarged thyroid. Low serum thyrotropin (TSH) and high free T4 and T3 concentrations establish the diagnosis. (See "Overview of the clinical manifestations of hyperthyroidism in adults".) Episodes of major depression may be secondary to general medical conditions (table 6); this is discussed separately. (See "Clinical manifestations and diagnosis of depression", section on 'Medical comorbidity'.) Medication history should be evaluated among elderly patients with new-onset mania or major depression, especially new treatments initiated by other clinicians (eg, steroids for arthritis, asthma, or inflammatory bowel disease; or dopaminergic drugs for Parkinson disease or restlessness legs syndrome) and complementary and alternative medications initiated by the patient (eg, St Johns wort for depression). Management of mood episodes secondary to a general medical condition includes concurrent treatment of the mood symptoms and general medical condition. Acute treatment of geriatric mood episodes is discussed separately. (See "Geriatric bipolar disorder: Acute treatment", section on 'Manic, hypomanic, and mixed episodes' and "Geriatric bipolar disorder: Acute treatment", section on 'Bipolar major depression'.) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topics (See "Patient information: Bipolar disorder (The Basics)" and "Patient information: Reducing the costs of medicines (The Basics)".) Beyond the Basics topics (See "Patient information: Bipolar disorder (manic depression) (Beyond the Basics)" and "Patient information: Reducing the costs of medicines (Beyond the Basics)".) These educational materials can be used as part of psychoeducational psychotherapy. (See "Bipolar disorder in adults: Maintenance treatment", section on 'Psychoeducation'.) The National Institute of Mental Health also has educational material explaining the symptoms, course of illness, and treatment of bipolar disorder in a booklet entitled "Bipolar Disorder," which is available online at the website http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml or through a toll-free number, 866-615-6464. The web site also provides references, summaries of study results in language intended for the lay public, and information about clinical trials currently recruiting patients. More comprehensive information is provided in many books written for patients and family members, including The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, written by David J. Miklowitz, PhD (published by The Guilford Press, 2002); An Unquiet Mind: A Memoir of Moods and Madness, written by Kay Jamison, PhD (published by Random House, 1995); and Treatment of Bipolar Illness: A Casebook for Clinicians and Patients, by RM Post, MD, and GS Leverich, LCSW (published by Norton Press, 2008). The Depression and Bipolar Support Alliance (http://www.dbsalliance.org or 800-826-3632) is a national organization that educates members about bipolar disorder and how to cope with it. Other functions include increasing public awareness of the illness and advocating for more research and services. The organization is administered and maintained by patients and family members, and has local chapters. The National Alliance on Mental Illness (http://www.nami.org or 800-950-6264) is a similarly structured organization devoted to education, support, and advocacy for patients with any mental illness. Bipolar disorder is one of their priorities.
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SUMMARY AND RECOMMENDATIONS The minimum age used to define geriatric bipolar disorder is generally 60 years. (See 'Definition' above.) The estimated lifetime prevalence of bipolar disorder in the United States general population aged 60 years or older is 1 percent. Geriatric patients represent between 7 and 25 percent of all bipolar patients. (See 'Epidemiology' above.) The pathogenesis of geriatric bipolar disorder is not known. However, the etiology of late-onset geriatric bipolar disorder (age 50 years or older) may possibly differ from earlier-onset bipolar disorder that has persisted into later life. (See 'Pathogenesis' above.) Bipolar disorder is characterized by episodes of major depression (table 1), mania (table 2), hypomania (table 3), and major depression concurrent with mania or hypomania. The clinical features of older and younger bipolar patients differ in that cognitive impairment is more common and severe in geriatric patients. In addition, general medical comorbidity occurs more often in geriatric bipolar patients than younger patients. By contrast, comorbid anxiety and substance use disorders appear to be less common in geriatric patients. (See 'Clinical features' above.) The assessment for geriatric bipolar disorder includes a psychiatric history and mental status examination, with emphasis upon depressive and manic symptoms. The work-up also includes a general medical history, physical examination, and focused laboratory tests and imaging studies that assess for general medical disorders such as hypertension, hyperlipidemia, diabetes, hypothyroidism, coronary heart disease, and asthma . (See 'Assessment' above and 'General medical disorders' above.) Self-report screening instruments that can save interviewer time and have been evaluated in mixed-age bipolar populations include the Mood Disorder Questionnaire (table 4), which screens for mania and hypomania, and the Patient Health Questionnaire - 9 Item (PHQ-9) (table 5), which screens for and diagnoses major depression. (See 'Screening' above.) There are three subtypes of bipolar disorder that can be diagnosed in elderly patients: bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified. (See 'Diagnosis' above and "Bipolar disorder in adults: Assessment and diagnosis", section on 'Diagnosis'.) The differential diagnosis of bipolar disorder includes schizophrenia, schizoaffective disorder, delusional disorder, unipolar major depression, and substance use disorders. In addition, mood episodes may be secondary to a general medical condition (table 6), including multiple sclerosis, stroke, brain tumor, concussion, infection with the human immunodeficiency virus (HIV), and hyperthyroidism. (See 'Differential diagnosis' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 14650 Version 5.0
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GRAPHICS DSM-IV-TR diagnostic criteria for major depression

A. Five (or more) of the following symptoms have been present during the same 2-week period, and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure.
(Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.) Depressed mood most of the day, nearly every day (or alternatively can be irritable mood in children and adolescents) Markedly diminished interest or pleasure in all, or almost all, activities, nearly every day Significant weight loss while not dieting, weight gain, or decrease or increase in appetite Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt nearly every day Diminished ability to think or concentrate, or indecisiveness, nearly every day Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of substance or a general medical condition. E. The symptoms are not better accounted for by Bereavement, ie, after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. American Psychiatric Association, Washington, DC 2000.
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DSM-IV-TR diagnostic criteria for mania

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1) Inflated self-esteem or grandiosity 2) Decreased need for sleep (eg, feels rested after only 3 hours of sleep) 3) More talkative than usual or pressure to keep talking 4) Flight of ideas or subjective experience that thoughts are racing 5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a mixed episode. D. The mood disturbance 1) is sufficiently severe to cause marked impairment in occupational functioning, usual social activities, or relationships with others, 2) necessitates hospitalization to prevent harm to self or others, or 3) has psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition (Copyright 2000). American Psychiatric Association.
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DSM-IV-TR diagnostic criteria for hypomania

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting at least 4 days, that is clearly different from the usual nondepressed mood. B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1) Inflated self-esteem or grandiosity 2) Decreased need for sleep (eg, feels rested after only 3 hours of sleep) 3) More talkative than usual or pressure to keep talking 4) Flight of ideas or subjective experience that thoughts are racing 5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode 1) is not severe enough to cause marked impairment in social or occupational functioning, 2) does not necessitate hospitalization, and 3) does not have psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism). Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (eg, medication, ECT, light therapy) should not count toward a diagnosis of bipolar II disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition (Copyright 2000). American Psychiatric Association.
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Mood disorder questionnaire

1. Has there ever been a period of time when you were not your usual self and... ...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? ...you were so irritable that you shouted at people or started fights or arguments? ...you felt much more self-confident than usual? ...you got much less sleep than usual and found you didn't really miss it? ...you were much more talkative or spoke faster than usual? ...thoughts raced through your head or you couldn't slow your mind down? ...you were so easily distracted by things around you that you had trouble concentrating or staying on track? ...you had much more energy than usual? ...you were much more active or did many more things than usual? ...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? ...you were much more interested in sex than usual? ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? ...spending money got you or your family into trouble? 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Please circle one response only. 3. How much of a problem did any of these cause you - like being unable to work; having family, money, or legal troubles; getting into arguments or fights? Please circle one response only. No problem Minor problem Moderate problem Serious problem Yes No Yes No
Patients screen positively for bipolar disorder if they answer "yes" to seven or more items in section 1, "yes" in section 2, and "moderate problem" or "serious problem" in section 3. The mood disorder questionnaire should not be used to diagnose bipolar disorder. Patients who screen positive should be interviewed to establish the diagnosis; including family members is often helpful.
Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000; 157:1873. Reprinted with permission from the American Journal of Psychiatry (Copyright 2000). American Psychiatric Association.
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PHQ-9 depression questionnaire

Name:
Over the last two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself, or that you are a failure, or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Total ___ = ___ + ___ + ___ + ___ 0 1 2 3 0 1 2 3 0 1 2 3 0 0 0 0 0 0 1 1 1 1 1 1
Date:
Not at all Several days More than half the days 2 2 2 2 2 2 3 3 3 3 3 3 Nearly every day
PHQ-9 Score 10: Likely major depression. Depression score ranges: 5 to 9: mild 10 to 14: moderate 15 to 19: moderately severe 20: severe If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all ___ Somewhat difficult ___ Very difficult ___ Extremely difficult ___
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and collegues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at rls@columbia.edu. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at www.pfizer.com. Copyright 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.
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General medical conditions causing or contributing to major depression ('Secondary Depression')

Drugs and Poisons
Alcohol, beta blockers, steroids, opiates, barbiturates, withdrawal from cocaine and amphetamines, heavy metal poisoning, cholinesterase inhibitors, cimetidine, chemotherapy agents
Metabolic/Endocrine
Hyper and hypothyroidism, severe anemia, hyperparathyroidism, hypokalemia, hyponatremia, Cushing's disease, Addison's disease, uremia, hypopituitarism, porphyria, Wilson's Disease, Wernicke-Korsakoff's syndrome
Infectious Diseases
Tuberculosis, Epstein-Barr infection, HIV, pneumonia, postinfluenza, tertiary syphilis, encephalitis, and post-encephalitic states
Neurodegenerative and Demyelinating Diseases

Alzheimer disease, multiple sclerosis, Parkinson disease, Huntington's disease
Other Neurologic
Subdural hematoma, normal pressure hydrocephalus, strokes, post-traumatic brain injury syndromes, cerebral tumors
Neoplasia
Carcinomatosis, cancers of the pancreas, lung, breast, and others
Others
Systemic lupus erythematosus, other collagen vascular disorders, other chronic inflammatory or auto-immune disorders, heart failure
Reproduced with permission from: Privitera, MR, Lyness, JM. Depression. In: The Practice of Geriatrics, 4th ed, Duthie, E Jr, Katz, PR, Malone, ML (Eds), W.B. Saunders, 2007. Copyright 2007 Elsevier.
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Geriatric Bipolar Disorder - Epidemiology, Clinical Features, Assessment, and Diagnosis PDF

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Geriatric Bipolar Disorder - Epidemiology, Clinical Features, Assessment, and Diagnosis PDF

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