Dr. Colin Depp, Associate Professor of Psychiatry at the University of California, San Diego and CREST.BD member, describes research on the changes, including positive ones, that occur as people grow older with bipolar disorder. He shares evidence and considerations for treatments for bipolar disorder in older adults, as well as an overview of the lifestyle and behavioral determinants of healthy aging. He also presents new research on the importance of these factors in aging well with bipolar disorder. Colin Depp, Ph.D. is an Associate Professor of Psychiatry at the University of California, San Diego. He is also Associate Director of Research Education and Training Division of the San Diego Clinical Translational Science Institute and psychologist at the Veterans Administration Healthcare System in San Diego. His research focuses on psychosocial interventions for bipolar disorder, use of technology for behavioral change, and the determinants of successful aging in people with mental illnesses. Dr. Depp is a principal investigator or co-investigator on multiple studies and he on the Editorial Board of Bipolar Disorders.

1. Successful Aging and Bipolar Disorder
Colin Depp, Ph.D., Associate Professor
UCSD Dept. of Psychiatry
Or

2. Overview
• Brief broad background on population aging
• Aging and bipolar disorder
• Interventions for older adults with bipolar disorder
• Applying healthy aging concepts to bipolar disorder
• Summary and discussion

3. AGE PYRAMID IN USA (Olshansky, 1997)
1900
80+
MALES FEMALES
(in
millions)
21st Century
80+
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4

4. Age Pyramids in Japan

5. Rapid Changes in Health of Older
People: The Civil War Studies
Fogel et al., 1998

6. Characteristics of the Civil War
Cohort
• 25% died in infancy
• 40% died before age 15
• Leading causes of death were infectious
disease
• Food clothing and shelter accounted for
75% of costs (now 13%)
• 3100 hours of work per year and two
hours per day of leisure (now 50%)

7. Components of Successful Aging
Absence
of
disease/
disability
SUCCESSFUL
Engagement
with life
High
AGING
cognitive and
physical
function
(Rowe and Kahn, 1998)

8. Overview
• Brief broad background on population aging
• Aging and bipolar disorder
• Interventions for older adults with bipolar disorder
• Applying healthy aging concepts to bipolar disorder
• Summary and discussion

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

10. Estimated Number of People with Major
Psychiatric Disorders by Age Group
16
15
14
13
12
11
10
9
8
7
2000 2010 2020 2030
Millions
18-29 30-44 45-64 65 >
Jeste, Alexopoulus, Bartels, et al., 1999

11. Years of Life Lost in Mental
Illness
Diagnosis Mean Years of Life
Lost
Schizophrenia 12.2
Bipolar Disorder 10.4
Substance Abuse 14.2
Depression 8.9
Chang et al., PLOS ONE 2011

12. Common Medical Conditions in
Patients Diagnosed with Bipolar
Disorder
35
25
Kilbourne AM, et al. Bipolar Disord 2004, 6: 368-373
17 15 15
11 11 10
6
25
100
90
80
70
60
50
40
30
20
10
0
Dyslipidemia
Alcohol Use d/o
Hypertension
Arthritis
Diabetes
Low Back Pain
Hepatitis C
IHD
COPD
Cocaine use d/o
%
Kilbourne AM, et al. Bipolar Disord 2004, 6: 368-373

13. Cross-Sectional Differences between BD,
Schizophrenia, and NCs in neurocognitive
measures (age 44-85)

14. Lifespan Predictors of Greater
Cognitive Impairment
+ Greater number of manic and depressive
episodes
+ Greater number of hospitalizations
+ Longer duration of illness
= Possible “neurotoxicity” associated with
symptom exacerbations
Robinson et al. 2008

15. Summary of Age-Associated
Changes in Late Life BD
Positive Changes Negative Changes
Substance abuse Cognitive/functional
impairment
Acuity of mania Depression remains?
Avoidance of treatment Medication/Medical
burden
External stressors/
Social conflict
Isolation

16. Applying successful aging to
mental illnesses
• What are the characteristics of people who
“succeed” despite having bipolar disorder?
• How do some patients “adapt well” to
bipolar disorder?

17. Resilience in Bipolar Disorder
“Having a mental illness is like pushing a
rock up a hill and it’s always coming back at
you. People see mentally ill people as weak.
To me, it takes even more strength than the
average person has.”
– David 64 Year Old with Bipolar I

18. Overview
• Brief broad background on population aging
• Aging and bipolar disorder
• Interventions for older adults with bipolar disorder
• Applying healthy aging concepts to bipolar disorder
• Summary and discussion

19. GERI-BD
• Only clinical trial of any treatment in older
adults with BD
• Comparison of 9 weeks of Lithium or
Valproate in adults older than age 60 in a
Manic, Mixed, or Hypomanic Episode
• High prevalence of cardiovascular burden
• Results: Both treatments were effective
with a low rate of adverse events
Young et al, 2010; 2013

20. Psychosocial Interventions for BD
• Cognitive-Behavioral Therapy (>8 RCTs)
• Family Focused Therapy (>4 RCTS)
• Interpersonal and Social Rhythms Therapy (>3
RCTs)
• Psychoeducation (>10 RCTs)
• Cognitive/Functional Remediation (1 RCTs)
Scott 2005; Lam 2008; Beynon et al. 2008

21. General Adaptation
Psychotherapy for Older Adults
1. Shorter (45 minute) and more sessions
2. Simpler, larger font worksheets
3. Physical illness and disability are the rule
not the exception – need to collaborate with
broader set of providers
4. Changes in cognition or mood have
complex causes
5. Older adults often prefer psychotherapy

22. Medication Adherence Skills Training –
BD (2008): Group Psychoeducation
Health Beliefs Model
Belief in
Illness
(Need for
medications)
Belief that
Benefits of
Medication
Outweigh Costs
Use Cues to
Engage in
Behavior
Immediate
Memory
Prospective
Memory
Longer-Term
Recall
Cognitive Aging Model of
Adherence
Rosenstock HA and Hansen DB. Am J Psychiatry 1974;131:1397-9.
Brown SC and Park DC. Gerontologist 2003;43:57-67.

23. Pre-Post Change in Adherence
Self Reported non-adherence to mood stabilizer in
50
45
40
35
30
25
20
15
10
5
50
45
40
35
30
25
20
15
10
5
Depp CA, et al. Bipolar Disord 2008;9:636-45; (N=16)
the past week
0
Percent
Baseline
Post-Treatment
Self-reported trouble taking all of prescribed
medications
0
Percent
Baseline
Post-Treatment

24. Cognitive Tasks Following Self-
Management Recommendations
• Typical
psychoeducation:
– Increasing awareness
of daily fluctuations
– Developing action
plans in case of
symptom
exacerbation
– E.G. “When I get
depressed, I will call a
friend for support…”
• Successful
implementation
requires people to:
– Pay attention to their
mood over time
– Remember what to
do, when to do it, and
why
– Engage in the plan
outside of the clinic
– Engage in the plan
when they feel worse
but before the “#$%#
Depp et al., 2010 JNMD hits the fan”

25. Personalized Real-Time Intervention for Stabilizing Mood
(PRISM)
Goal: Transporting psychoeducation to real-time
Basis: Life Goals Manual (Bauer et al., 2009)
Intervention: 4 in-person sessions and
subsequent responding on mobile phone
1. Identification of self-management strategies by
phase of illness or early warning sign
2. Education on optimal ways of implementing
strategy
3. Phrase self-management messages to self

26. Example Implementation
Intentions
“If I am mildly manic …
I’ll give my motorcycle
keys to [my wife] …
to be safe”
Situation/State
Specific
Behavior
Benefit
Gollwitzer and Sheeran (2006)

27. Data
Personalized feedback
Mood
Heart rate
8
6
4
2
0
Week
GPS/location/activity level
Sampling Rate

28. Overview
• Brief broad background on population aging
• Aging and bipolar disorder
• Interventions for older adults with bipolar disorder
• Applying healthy aging concepts to bipolar disorder
• Summary and discussion

29. Pessimistic View of Behavioral
Determinants of Successful
Aging as Applied to BD

30. Behavioral Determinants of
Successful Aging
• Exercise
• Diet
• Cognitive stimulation
• Optimism/resilience
• Social integration
• Positive attitudes toward aging
• Stress reduction
Depression

31. Peak ages of physiological performance
• Hearing peaks at 5 years old
• Smell peaks at 10 years old
• Taste peaks at 10 years old
• Flexibility and balance peaks at 13 years old
• Muscle strength peaks at 18 years old
• Tissue repair peaks at 13 years old
• Short term memory peaks at 20 years old
• Immune response peaks at 13 years old
• Lung capacity peaks at 20 years old
Cutler and Mattson (2007) Ageing Res Reviews

32. Caloric Restriction: Extends the
Lifespan in Multiple Species
One for the Age: A prescription that may extend life. New York Times. (Oct 31, 2006).

33. Optimistic View of Modifiable
Factors in Successful Aging

34. Potentially Modifiable Factors
in Successful Aging
• Exercise
• Diet
• Cognitive stimulation
• Optimism/resilience
• Social integration
• Positive attitudes toward aging
• Stress reduction
Depression

35. Life Satisfaction by Age
http://www.princeton.edu/~rpds/downloads/Deaton_Aging_and_wellbeing_around_the_world_Aug_07_ALL.pdf

36. Exercise as effective as antidepressants in
treating major depression in older adults
Blumenthal et al., JAMA 1999

37. Cognitive Training and Depression

39. Shared Mechanisms of Aging
Interventions
Mattson et al., 2002

40. Effect of a Healthy Lifestyle:
Nurses Health Study (n=84,129)
Examined the effect of the following combination of
behaviors:
• Not currently smoking
• Low/moderate alcohol consumption
• ½ hour of moderate physical activity per day
• Diet that was:
– High in cereal fiber
– High in marine n–3 fatty acids,
– High ratio of polyunsaturated to saturated fat
– Low in trans fat
– Low in glycemic load
N Engl J Med. 2000 Jul 6;343(1):16-22

41. Effect of a Healthy Lifestyle:
Nurses Health Study (n=84,129)
Dietary score and risk for Heart Disease in women from the Nurses’
Health Study.
Stampfer et al,6
N Engl J Med. 2000 Jul 6;343(1):16-22

42. BMI and Cognitive Ability in
Serious Mental Illness
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
Bipolar Disorder
(n=341)
Schizophrenia
(n=417)
Normal (BMI 18-25)
Overweight (BMI 25-
30)
Obese (BMI 30+)
z-scores (stand err)
Depp et al., Bipolar
Disord., In press

43. Smoking History and Cognitive
Functioning
Depp et al., In Press

44. Summary of Modifiable
Factors in Successful Aging
• Exercise
• Diet
• Mental activities
• Optimism
• Social integration
• Positive attitudes toward aging
• Stress reduction
• Regular health screenings

45. Summary
• Many people with bipolar disorder are
older adults (and more are coming!)
• Treatment works but should be adapted to
cognitive and physical changes
• Bioehavioral determinants of successful
aging are:
– Negatively impacted by bipolar disorders AND
– Potential treatment targets in bipolar disorder

46. THANK YOU !!!
aging.ucsd.edu