Mohammed T. Abou-Saleh

96 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYlater years. It has only recently been recognized in the USA, andthere have been very few community-based studies examiningoutcomes. There is some suggestion, however, that those personswith onset later in life are able to function better in the communitybecause occupational and social roles have not been interruptedby the disorder earlier in life 5 .There has been more research attention focused on depressionduring later life and although there have been widespread reportsof a high prevalence among this population, epidemiologicalstudies have not confirmed this impression 7 . But it is unclearwhether the relatively low rates of depression at older agesare artifacts of epidemiological definitions and methods. Subthresholdnegative affect appears very high in this population,leading many internists and geriatricians who care for the elderlypopulation to believe that epidemiological estimates are biasedand do not reflect the real situation. Depression is clearly differentin elderly persons than in early and middle adulthood because ofcomplex physical co-morbidities, decrements in function andrelationship losses that occur in later life. Older persons are alsoless likely to acknowledge psychological manifestations ofdepression, see mental health treatment as more stigmatizingand resist referral to mental health specialists. Assessing depressionwithin the constellation of physical concomitants that mightbe attributed to a variety of other conditions poses diagnosticchallenges for the general physician. There are presently a numberof ongoing experimental efforts to improve the recognition andtreatment of depression among the elderly in primary care 8 .Most studies examining depression among elderly persons havenot dated the onset of the disorder. There is some suggestion,however, that biological or genetic vulnerability may play a lesserrole in the etiology of first onset of major depression or bipolardisorders late in life than earlier 9,10 . Late-onset depression andbipolar disorder appear to be triggered more commonly bymedical and neurological co-morbidities, while onset earlier inadulthood is more strongly correlated with the occurrence ofenvironmental stressors 10 . Much remains to be learned about theetiology of late-onset disorders but the role of social factors willvary with age.Recent research reports a gender difference in late-onsetschizophrenia, with older women having greater risk 5 , althoughthe reason for this difference remains unclear. There is also agender difference in depression but, unlike schizophrenia, itdevelops in early adolescence and persists across the life course.The relationship is a complex one and is a matter of continuingcontroversy. Since abuse of alcohol and drugs and violence aremore common among men, and depressed affect more commonamong women, some explain the two-fold prevalence difference interms of varying gender-related reaction patterns 11 . Others haveargued that the higher rates of reported and diagnosed depressiveillness in women result from a greater prevalence of morecommon and less serious symptoms of depression reported bywomen, such as sadness and crying, and their greater willingnessto report affective symptoms 12 . The issues remain unresolved, withdifferent views depending in part on varying conceptions of thenature of depressive disorders.Whatever the eventual resolution of these issues, the data dosuggest that women in later life are at greater risk for symptoms ofschizophrenia and depression than are their male counterparts. Atthe same time, older women are more likely than older men to bewithout a partner and they also experience greater economicdisadvantage, both of which may exacerbate the negativeconsequences of mental disorder.There is a long-established relationship between socioeconomicstatus and severe mental illness and decades of debate about therelative influence of causative vs. selection factors for explainingthe higher prevalence of schizophrenia among those of lowersocioeconomic status 13,14 . The weight of the evidence supports theview that the impairment associated with schizophrenia preventsupward mobility comparable to one’s age cohort and loss of socialposition because of difficulties completing one’s education andmaintaining employment.Early onset of major depression or bipolar disorder may alsoimpair upward mobility, but socioeconomic status also appears toaffect the onset of major depression. A variety of studies suggestthat the etiological significance of socioeconomic status indepression relates to the prevalence of major life stresses andpersistent difficulties and the lower availability of coping resourcesand social supports 15 .Disadvantages associated with socioeconomic status putpersons with mental illness at risk for a number of negativeoutcomes that are not directly associated with the illness.Inadequate housing or homelessness remain significant problemsfor persons with mental illnesses and compromise efforts toprovide meaningful services, yet we know very little about theseissues in older populations 16 . Economic disadvantage is also asubstantial barrier to access to health services and prescriptionmedications in countries without universal health coverage 17 .These problems may be accentuated in later life for those withlimited resources.Socioeconomic status also helps to explain differences in mentalhealth outcomes for different race and ethnic groups in the USA.While there do not appear to be major race/ethnic differences inthe prevalence of severe mental illnesses independent of socioeconomicstatus, these factors significantly influence the course ofillness. In the USA, rates of services utilization are lower forMexican Americans, Asian Americans, and African Americansthan Whites, when need for services is taken into account 18 .Economic barriers to access to health services contribute to thisgap between need and service utilization among certain race andethnic groups. Cultural differences in attitudes toward mentalhealth services, perceived stigma and discrimination may also playa role 19 .The importance of family for the onset and course of mentalillness has been commonly examined. The onset of severe mentaldisorder early in life increases the likelihood of remainingunmarried, especially for men, and increases the risk of divorceand separation among those who do marry 20 . Thus, many personswith severe mental illness will enter their later years without thebenefits of a partner to provide emotional and instrumentalsupport.Styles of interaction within the family are also important. Mostof the research has been focused on schizophrenia and suggeststhat a highly involved critical orientation to the patientcontributes to relapse 21 . Instruction of families based on theseprinciples has been found to be useful in some controlled trials,and offers a conceptual basis for psychoeducationalapproaches 21,22 .Increasing research in mental health focuses on stress and thecoping process and the role of social support in either bufferingthe effects of stress or independently contributing to emotionalwell-being. While such factors as stressful events, copingresources, intimate and instrumental relations and self-efficacyhave all been found to be associated with variations inpsychological distress, their significance for major mental illnessis less clear. Moreover, the role of these factors is conditionspecific.In schizophrenia, stress acts as a trigger, affecting theoccurrence and timing of episodes 23 . In affective disorder, incontrast, stressful events and meanings assigned to these eventsappear to play a more causative role in conjunction with otherfactors 12 . There is recent evidence that childhood adversity, suchas separation from parents or sexual and physical abuse, maytrigger onset of depressive disorders well into adulthood 24 .While, in general, it is believed that social support is important,the forms of social support useful to varying kinds of patients at