Mental Health & Aging

Older Patients With Schizophrenia:

Challenges in the Coming Decades
Barton W. Palmer, Ph.D.
Shelley C. Heaton, B.A.
Dilip V. Jeste, M.D.

The number and proportion of older adults with schizophrenia will increase considerably in the coming decades. Although a vast literature on
schizophrenia among younger adults exists, much less is known about
late-life schizophrenia and its treatment. The authors describe two potential scenarios for 2011, the year that the first baby boomers will turn
65. To ensure that the more favorable scenario becomes a reality, the authors suggest four goals: decrease medical comorbidity and mortality
among younger patients with schizophrenia and improve their access to
health care so that they can live longer and more productive lives; improve our understanding of the neurobiological and psychosocial factors
underlying late-life schizophrenia, as well as the health care and social
service needs of such patients; develop more effective and safer pharmacologic, psychosocial, and cognitive behavioral treatments; and improve rehabilitation of older people with schizophrenia. Specific strategies to foster these goals include establishing a consortium for studies of
late-life schizophrenia; conducting multicenter studies of treatment effectiveness; and forming interdisciplinary collaborations among researchers, clinicians, government and industry representatives, and patient advocacy groups. (Psychiatric Services 50:11781183, 1999)

chizophrenia is often thought of

as a disorder affecting adolescents and young adults, but the
coming decades will bring about an
unprecedented increase in the number and proportion of elderly Americans with this disorder. The first
members of the baby-boom generation turn 65 in the year 2011, which
will begin a rapid increase in the
number of elderly persons within the
general population (1). Also, development of additional treatment options
may reduce mortality from this disor-

der. For example, up to 13 percent of

people with schizophrenia commit
suicide (2), but treatment with clozapine has been reported to decrease
the suicide risk among patients unresponsive to traditional neuroleptics
(3). Unfortunately, relatively little research has been done on late-life
schizophrenia. In 1996 Jeste (4)
found that only about 6 percent of the
schizophrenia studies in current issues of leading psychiatric journals
focused on older patients.
This review is part of a larger effort

The authors are affiliated with the department of psychiatry at the University of California, San Diego. Ms. Heaton is also with the department of psychology at San Diego State
University. Dr. Jeste is also with the psychiatry service of the San Diego Veterans Affairs
Medical Center. Send correspondence to Dr. Palmer at the Geriatric Psychiatry Intervention Research Center (116A-1), Veterans Affairs San Diego Healthcare System, 3350
La Jolla Village Drive, San Diego, California 92161 (e-mail, bpalmer@ucsd.edu). This paper is part of a special section on meeting the mental health needs of the growing population of elderly persons.
1178

to propose steps to prepare for the

upcoming crisis in geriatric mental
health care (5). We briefly outline the
current state of affairs and make specific recommendations for meeting
the challenges related to schizophrenia in late life.

What is late-life schizophrenia?

The phrase late-life schizophrenia
refers to older patients who first manifested schizophrenia in early adulthood, as well as to those whose symptoms first appeared in later life (6).
According to the Epidemiologic
Catchment Area (ECA) studies (7),
the lifetime prevalence of schizophrenia among people age 65 years
and older is only .3 percent, and the
one-year prevalence is .2 percent.
We believe that several methodologic aspects of the ECA studies may
have caused an underestimation of
the prevalence of schizophrenia
among the elderly population. These
studies used DSM-III criteria (8),
which did not permit the diagnosis of
late-onset schizophrenia and did not
include negative symptoms, and they
undersampled areas with higher rates
of mentally ill elderly persons such as
public housing (9). The reliance on
retrospective self-reports in the ECA
studies also has obvious limitations
for older patients with schizophrenia.
Thus the true current prevalence of
schizophrenia in the elderly population is unknown, but it is probably
higher than the ECA figures suggest.
Early-onset schizophrenia

Kraepelins original conception of

dementia praecox was that this disorder was typified by onset in adolescence or young adulthood, with a

PSYCHIATRIC SERVICES

September 1999 Vol. 50 No. 9

progressive decline in functioning

thereafter (10). Consistent with this
view, Davidson and associates (11)
reported that more than 60 percent
of their sample of chronically institutionalized patients with schizophrenia had diagnosable dementia. However, chronic institutionalization is
atypical for most elderly patients
with schizophrenia and is experienced by only the most severely ill
sector of the population with schizophrenia (12). The decline pictured by
Kraepelin appears to characterize the
outcome for about 20 percent of patients, while another 20 to 30 percent
experience marked improvement or
even recovery (1315).
A related issue is the notion of
schizophrenic burnout. It involves a
deficit state, with a disappearance of
positive symptoms, such as delusions
and hallucinations, and an increase in
negative symptoms, such as social
withdrawal, affective flattening, and
avolition. This pattern may describe
the course seen in a small minority of
patients, but a majority of older patients with schizophrenia continue to
have both positive and negative
symptoms, and another minority have
substantial improvement in both
types of symptoms (1618).
The reasons for the recovery seen
in some patients in later life are not
fully clear. One possibility is changing
role expectationspatients who were
unable to meet the challenges of
young adulthood may have less difficulty meeting role expectations associated with later life, which are typically less challenging. However, we
do not believe that this is the main
reason for recovery. Neurobiological
changes associated with later life that
may foster a decrease in psychotic
symptoms have been documented; an
example is reduction in dopamine activity (19).
The rates of full remission remain
uncertain, but there are clear examples of people with schizophrenia
who show remarkable recovery after
many years of chronic dysfunction. A
recently publicized example of recovery is that of John Nash, a Nobelprize-winning mathematician who
developed schizophrenia in his late
twenties (18). Dr. Nashs symptoms
remitted after decades of severe illPSYCHIATRIC SERVICES

ness, whereupon he returned to a

productive academic career in mathematics.
Patient characteristics that are associated with better outcome include
good premorbid adjustment, acute
onset of symptoms, short duration of
an ongoing episode, and a paucity of
negative symptoms (20,21). According to Wyatt (22), early intervention
with antipsychotic medications during patients first psychotic episode
may also lead to a better long-term
outcome.
Late-onset schizophrenia

The historical tendency to view schizophrenia as having an onset restricted

to adolescence or young adulthood

The
lifetime
prevalence of
schizophrenia across all
age groups is only about 1
percent, yet it accounts for
the largest proportion of
mental health care
expenditures.

was formalized in criteria put forth by

Feighner and colleagues (23) and in
DSM-III criteria (8), which did not
permit diagnosis of schizophrenia if
symptoms developed after age 40 or
45, respectively. However, a number
of reports challenged this notion (24
28). DSM-III-R (29) permitted diagnosis of schizophrenia late-onset type
after age 45, and DSM-IV (30) includes no age-of-onset restriction for
diagnosis of schizophrenia.
It has been suggested that late-onset schizophrenia is a neurodegenerative condition (31), results from acquired brain lesions (32), or is secondary to sensory deficits and inter-

September 1999 Vol. 50 No. 9

personal isolation (3335). Such theories suggest that patients with late-onset schizophrenia have relatively normal brain and psychosocial functioning before the onset of these triggering changes. Our studies challenge
these views.
In investigations conducted at the
Clinical Research Center for the
Study of Late-Life Psychoses at the
University of California, San Diego,
patients with late-onset schizophrenia
(those whose age at onset of schizophrenia was 45 years or older) were
compared with patients of a similar
age who had earlier onset of schizophrenia (16). Similarities between the
groups included the severity of positive symptoms, chronicity of course,
level of uncorrected sensory impairment, family history of schizophrenia,
early childhood maladjustment, increased mortality relative to the general population, qualitative response
to neuroleptic medications, overall
pattern of neurocognitive impairment, and presence or absence of
gross structural brain abnormalities
seen via neuroimaging. Similar to early-onset patients, patients with lateonset schizophrenia also had an elevated number of minor physical
anomalies compared with normal
subjects, suggesting subtle aberrations in their early development (36).
Several differences between earlyand late-onset patients were also observed in these studies (16). Patients
with late-onset schizophrenia were
more likely to be women and to have
the paranoid subtype of the disorder.
They had less severe negative symptoms, better premorbid functioning
in early adulthood, and less impairment in the specific neurocognitive
areas of learning and abstraction or
cognitive flexibility, and they required
lower dosages of neuroleptic medications for management of their psychotic symptoms. Quantitative analyses of MRI scans in a subsample of
patients showed larger thalami in the
late-onset group than in the early-onset group (37).
The similarities observed between
patients with early- and late-onset
schizophrenia suggest that the latter
is true schizophrenia, in that the
two groups were similar in terms of
apparent genetic risk, positive symp1179

toms, treatment response, and

course. On the other hand, the differences between these groups suggest
that neurobiologic differences might
mediate the onset of schizophrenic
symptoms (3840). Elucidation of
such mediating factors may suggest
novel intervention or prevention
strategies.

The cost of schizophrenia

The lifetime prevalence of schizophrenia across all age groups is only
about 1 percent, yet it accounts for
the largest proportion of mental
health care expenditures (41). It has
been estimated that the direct and indirect costs of schizophrenia to the
U.S. economy in 1991 alone totaled
approximately $65 billion (42). The
cost of schizophrenia in elderly patients is at least as high as that incurred by patients in their late teens
and 20s (43).
The impact of an aging population
on the national health budget can be
seen in figures for 1987: 57.9 percent
of public health care expenditures
were for persons age 65 and above
(1), but this age group represented
less than 13 percent of the population
(44). During the 21st century a dramatic increase in geriatric mental
health care costs can be expected. It
will occur in parallel with an expansion in general health care expenditures due to the aging population.
In addition to the monetary impact,
late-life schizophrenia can have an
adverse impact on the quality of life
of patients and their families. In one
study older patients with schizophrenia were found to have a significantly
lower quality of well-being than normal comparison subjects (45). In fact,
these patients scores were slightly
worse than those of ambulatory AIDS
patients.

Treatment
Conventional neuroleptic agents are
effective in managing the positive
symptoms of many patients, but
chronic use is associated with a risk of
motor system side effects such as tardive dyskinesia (46). The cumulative
annual incidence of tardive dyskinesia
among older outpatients treated with
low dosages of conventional antipsychotic medications is 29 percent (46),
1180

which is about six times that reported

for younger adults (47).
Studies involving predominantly
younger, physically healthy patients
with schizophrenia suggest that the
newer atypical antipsychotic medications (the serotonin- and dopamineblocking antipsychotics) are somewhat more effective than traditional
neuroleptics in treating the negative
symptoms of schizophrenia while being associated with a lower risk of extrapyramidal symptoms and perhaps
tardive dyskinesia (4851). On the
other hand, large-scale studies evaluating the relative effectiveness and
safety of these newer atypical antipsychotics for older patients with schizophrenia are lacking.

schizophrenia in 2011, when the first

members of the baby-boom generation turn 65.
The dream scenario

Development of better antipsychotic

compounds with improved efficacy
and side effect profiles will reduce the
need for costly inpatient treatment.
Treatment advances, including refinement of psychotherapeutic, nonpharmacologic interventions, will facilitate
an age-appropriate level of normal
daily functioning as well as an improved quality of life for both patients
and their caregivers. Improved access
to health care and to the necessary
community support services along
with reduced social stigma will enable
patients to join the mainstream of society in a productive fashion.
The nightmare scenario

Current
thinking about
schizophrenia in older
adults is often quite
pessimistic and is unduly
influenced by work among
institutionalized
patients.

Another potential barrier to the

use of atypical antipsychotic medications by elderly patients is their cost
compared with traditional neuroleptics (52). Pharmacoeconomic analyses involving primarily younger patients suggest that use of atypical antipsychotic medications may be associated with a reduction in the total
dollar cost of the disorder, but, again,
data are lacking to evaluate the overall cost-benefit ratio of using these
medications with older patients
(53,54).

In the absence of more effective,

safer, and affordable treatments, noncompliance with treatment will continue to be a problem. The result will
be an unacceptably high relapse rate,
with a need for institutionalization.
Meanwhile, managed care companies
may make it harder to hospitalize patients. A continued lack of insurance
coverage for mental illnesses and further erosion of Medicare will lead to a
decrease in the number of older persons with schizophrenia in the health
care system. Unfortunately, this decrease will be achieved through increased mortality and perhaps an increase in patients in the criminal justice system (42). Neglect of research
into psychotherapeutic and other
treatments will foster continued ostracism of elderly persons with schizophrenia from the rest of the society.

Analyzing the challenges

Current actions can largely determine whether the dream or nightmare scenario characterizes the state
of affairs in 2011 and beyond. The following discussion is an analysis of the
strengths, weaknesses, opportunities,
and threats of the situation.
Strengths

The expected state

of affairs in 2011
Current trends suggest a possibility of
two scenarios for older patients with

Demographic imperative. The number and proportion of people over age

65 with schizophrenia will increase.
Implications of societal costs.

PSYCHIATRIC SERVICES

September 1999 Vol. 50 No. 9

The dream scenario is not necessarily

the more costly scenario. We can
spend the money on research and
training now or spend more on institutionalization a few years from now.
High potential for success. The
expertise to meet this challenge exists
today. Cooperative efforts by the government and the private sector and
by mental health professionals are
necessary for making significant gains
in the understanding and treatment
of late-life schizophrenia.
Success of atypical antipsychotics. The recent advent of atypical antipsychotics with superior therapeutic effects and fewer side effects
has been a significant leap forward in
the treatment of schizophrenia. A
fringe benefit of this development has
been the pharmaceutical industrys
increasing interest in antipsychotics.
Neuroleptics have not traditionally
yielded large profit margins for drug
companies, so they were reluctant to
spend research dollars on their refinement. The success of atypical antipsychotics has fostered a positive
mindset within the pharmaceutical
industry toward developing new and
better antipsychotic medications.
Survivors. Elderly patients with
schizophrenia can be viewed as survivors. In this light they can teach the
general community much about coping with the challenges presented by
a chronic illness.
Weaknesses

Double social stigma. A double social stigma exists in relation to schizophrenia and aging. Lack of a political
voice in this patient group and a bias
in our society toward youth and
health result in societal neglect of the
needs of aging people with schizophrenia. Ignorance about the problem extends to many health care
providers, mental health care workers, researchers, and public policy
makers (4,55).
Lack of clinical data. More data
are needed to guide rational clinical
practice with aging patients who have
schizophrenia. Few studies have focused on the effectiveness of interventions (4,56).
Pessimistic attitudes. Current
thinking about schizophrenia in older
adults is often quite pessimistic and is
PSYCHIATRIC SERVICES

unduly influenced by work among institutionalized patients, even though

the large majority of patients live in
the community and not in state hospitals or nursing homes (12,25).
Increased substance abuse. In
the future cohort of elderly people,
including those with schizophrenia,
more people are likely to have a history of substance abuse (57).
Research difficulties. Conducting research among older persons
with schizophrenia is often challenging because of cognitive impairment,
sensory deficits, medical comorbidity,
polypharmacy, biological and psychosocial heterogeneity, and a frequent lack of caregivers. Also, the potential impact of this disorder on decision making and other cognitive
skills, particularly in an age group at
risk for cognitive decline, complicates
ethical issues regarding informed
consent (58,59).
Opportunities

Collaboration. We can produce a

unique model of collaboration among
advocates for mental health and aging, including scientists, professional
organizations, government agencies
such as the National Institutes of
Health and the Department of Veterans Affairs, advocacy groups for the
mentally ill and elderly populations
such as the National Alliance for the
Mentally Ill and the American Association of Retired Persons, the pharmaceutical industry, private foundations,
and others.
Prevention. The means for primary prevention of schizophrenia are
not on the immediate horizon, but
much may be learned about factors
associated with delayed onset and remission of the illness in old age.
Advances. Unprecedented advances are taking place in changing
our traditional understanding of the
aging process. These advances are occurring at a basic science level as well
as a clinical science level, challenging
the notion of inevitability of age-related declines (60,61).
Threats

Competition for funds. An increasing number of special-interest groups

are competing aggressively for dollars
in an era when politicians are hesitant

September 1999 Vol. 50 No. 9

to be seen as increasing public expenditures.

Lack of collaboration. There has
been a lack of sufficient collaboration
among many of the groups that need
to work together for the necessary initiatives.
The pervasiveness of traditional
ideas. The influence of traditional
thinking about schizophrenia remains
pervasive. For example, the Kraepelinian notion of dementia praecox
retards efforts for rehabilitation in
late-life schizophrenia.

Specific goals and

suggested strategies
Goals

Four specific goals can be identified.

In the short term we should attempt to increase the number of older people with schizophrenia in the
population by decreasing medical comorbidity and mortality among
younger patients and improving patients access to health care.
We should continue to seek to
improve our understanding of the
neurobiological and psychosocial
factors underlying late-life schizophrenia, as well as of the health care
and social service needs of such patients.
We should develop more effective and safer pharmacologic, psychosocial, and cognitive-behavioral
treatments.
Rehabilitation efforts for older
people with schizophrenia should be
expanded and improved, with better
social support services and greater
help for patients caregivers.
Strategies

Several steps will be necessary to

meet the above goals, including development of age-appropriate diagnostic criteria, expansion of the research infrastructure to explore the
interaction of schizophrenic neuropathology and psychosocial deficits
with the normative aging changes,
and translation of such research into
clinical practice and public policy.
Specific strategies to foster the occurrence of these steps include:
A consortium for studies of older
adults with schizophrenia should be
formed. Pooling resources will decrease the cost of research and make
1181

the collection and dispersion of

knowledge obtained more efficient.
Greater emphasis should be
placed on multicenter cooperative
studies of treatment effectiveness,
particularly research that directly
translates into clinical care of elderly
patients (62).
Interdisciplinary collaboration
among researchers, clinicians, government and industry representatives, and advocacy groups for patients and elderly persons should be
encouraged.

Conclusions
The challenges presented by the upcoming increase in the number and
proportion of older patients will force
us to pay closer attention to the longitudinal course of schizophrenia and
the interaction of neurocognitive
deficits, psychiatric symptoms, and
their treatment with the psychosocial
and physical changes associated with
normal aging. This challenge may
serve as a catalyst in turning the field
and our society away from the myopic
and pessimistic perspective that has
characterized much of the research
and thinking about late-life schizophrenia.
Research focused on late-onset
schizophrenia may provide unique insights into the factors differentiating
vulnerability to schizophrenia from
its phenotypic expression. For example, involvement of the thalamus in
the expression of schizophrenic symptoms has been suspected for at least
40 years (63), but its precise role remains unclear. Recent findings of
larger thalamic volume among patients with late-onset schizophrenia
(37) could reflect a protective factor
(responsible for the later onset), a
pathological factor (responsible for a
particular form of schizophrenic vulnerability), or an epiphenomenon of
neuroleptic treatment. Documentation of any of these possibilities may
provide important insights into the
neurobiology of schizophrenia and its
treatment. Similarly, the higher prevalence of women among those with
late-onset schizophrenia has generated recent interest in the possibility of
estrogen replacement as an alternative form of antipsychotic therapy for
older women (64).
1182

If the current state of affairs continues, older patients with schizophrenia will continue to have high comorbidity and mortality and may require institutionalization at a considerable financial and emotional cost.
By cooperating and uniting our efforts to understand schizophrenia and
its treatment in late life, as well as by
using our combined political muscle
to ensure that the needed changes are
made in the allocation of research
dollars and mental health coverage, a
greater number of persons with schizophrenia will live longer and more productive lives.
Acknowledgments
This work was partly supported by grants
K07-MH-0145, MH-43693, MH-49671,
MH-45131, and MH-42522 from the National Institute of Mental Health and by
the Department of Veterans Affairs.

References
1. Hobbs FB, Damon BL (eds): 65+ in the
United States. Washington DC, US Bureau
of the Census, 1996
2. Caldwell CB, Gottesman II: Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophrenia Bulletin 16:
571589, 1990
3. Meltzer HY: Suicide in schizophrenia: risk
factors and clozapine treatment. Journal of
Clinical Psychiatry 59(suppl 3):1520, 1998
4. Jeste DV: Growing disparity between need
and reality: research in geriatric psychiatry.
Current Opinion in Psychiatry 9:279280,
1996
5. Jeste DV, Alexopoulous GS, Bartels SJ, et
al: Consensus statement on the upcoming
crisis in geriatric mental health: research
agenda for the next two decades. Archives
of General Psychiatry, in press
6. Harris MJ, Jeste DV: Late-onset schizophrenia: an overview. Schizophrenia Bulletin 14:3955, 1988
7. Robins LN, Regier DA (eds): Psychiatric
Disorders in America: The Epidemiologic
Catchment Area Study. New York, Free
Press, 1991

tionalized geriatric schizophrenic patients.

American Journal of Psychiatry 152:197
207, 1995
12. Cohen CI: Outcome of schizophrenia into
later life: an overview. Gerontologist 30:
790797, 1990
13. Bleuler M: The Schizophrenic Disorders:
Long-Term Patient and Family Studies.
Translated by Clemens SM. New Haven,
Conn, Yale University Press, 1978
14. Ciompi L: Catamnestic long-term study on
the course of life and aging of schizophrenics. Schizophrenia Bulletin 6:606618,
1980
15. Harding CM, Brooks GW, Ashikaga T, et al:
The Vermont longitudinal study: II. longterm outcome of subjects who once met the
criteria for DSM-III schizophrenia. American Journal of Psychiatry 144:727735,
1987
16. Jeste DV, Symonds LL, Harris MJ, et al:
Non-dementia non-praecox dementia praecox? Late-onset schizophrenia. American
Journal of Geriatric Psychiatry 5:302317,
1997
17. Gross G, Huber G, Schuttler R: Long-term
course of Schneiderian schizophrenia, in
Schizoaffective Psychoses. Edited by Marneros A, Tsuang MT. Berlin, Springer-Verlag, 1986
18. Nasar SA: A Beautiful Mind. New York, Simon & Schuster, 1998
19. Arranz B, Blennow K, Ekman R, et al:
Brain monoaminergic and neuropeptidergic variations in human aging. Journal of
Neural Transmission 103:101115, 1996
20. Ram R, Bromet EJ, Eaton WW, et al: The
natural course of schizophrenia: a review of
first-admission studies. Schizophrenia Bulletin 18:185207, 1992
21. Mental Disorders: Glossary and Guide to
Their Classification in Accordance With
the Ninth Revision of the International
Classification of Diseases. Geneva, World
Health Organization, 1978
22. Wyatt RJ: Neuroleptics and the natural
course of schizophrenia. Schizophrenia
Bulletin 17:325351, 1991
23. Feighner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry 26:
5763, 1972
24. Fish F: Senile schizophrenia. Journal of
Mental Science 106:938946, 1960

8. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC,
American Psychiatric Association, 1980

25. Rabins P, Pauker S, Thomas J: Can schizophrenia begin after age 44? Comprehensive
Psychiatry 25:290293, 1984

9. Rabins PV, Black B, German P, et al: The

prevalence of psychiatric disorders in elderly residents of public housing. Journal of
Gerontology: Medical Sciences 51A:M319
324, 1996

26. Gold DD Jr: Late age of onset schizophrenia: present but unaccounted for. Comprehensive Psychiatry 25:225237, 1984

10. Kraepelin: Dementia Praecox and Paraphrenia, 1919. Translated by Barclay RM.
Huntington, NY, Krieger, 1971
11. Davidson M, Harvey PD, Powchik P, et al:
Severity of symptoms in chronically institu-

27. Essa M: Late-onset schizophrenia (ltr).

American Journal of Psychiatry 139:1528,
1982
28. Harris MJ, Cullum CM, Jeste DV: Clinical
presentation of late-onset schizophrenia.
Journal of Clinical Psychiatry 49:356360,
1988

PSYCHIATRIC SERVICES

September 1999 Vol. 50 No. 9

29. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, rev. Washington, DC,
American Psychiatric Association, 1987
30. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC,
American Psychiatric Association, 1994
31. Murray RM, OCallaghan E, Castle DJ, et
al: A neurodevelopmental approach to the
classification of schizophrenia. Schizophrenia Bulletin 18:319332, 1992
32. Miller BL, Lesser IM, Boone KB, et al:
Brain lesions and cognitive function in latelife psychosis. British Journal of Psychiatry
158:7682, 1991
33. Roth M: Interaction of genetic and environmental factors in the causation of schizophrenia, in Schizophrenia: Somatic Aspects. Edited by Richter D. New York,
Pergamon, 1957
34. Cooper AF, Curry AR, Kay DWK, et al:
Hearing loss in paranoid and affective psychoses of the elderly. Lancet 2:851854,
1974
35. Varner RV, Gaitz CM: Schizophrenic and
paranoid disorders in the aged. Psychiatric
Clinics of North America 5:107118, 1982
36. Lohr J, Alder M, Flynn K, et al: Minor
physical anomalies in older patients with
late-onset schizophrenia, early-onset schizophrenia, depression, and Alzheimers disease. American Journal of Geriatric Psychiatry 5:318323, 1997
37. Corey-Bloom J, Jernigan T, Archibald S, et
al: Quantitative magnetic resonance imaging in late-life schizophrenia. American
Journal of Psychiatry 152:447449, 1995

46. Jeste DV, Rockwell E, Harris MJ, et al:

Conventional versus newer antipsychotics
in elderly patients. American Journal of
Geriatric Psychiatry 7:7076, 1999
47. Kane JM, Woerner M, Lieberman J: Tardive dyskinesia: prevalence, incidence, and
risk factors. Journal of Clinical Psychopharmacology 8(suppl 4):52S56S, 1988
48. Kane JM, Honigfeld G, Singer J, et al:
Clozapine for the treatment-resistant schizophrenic: a double-blind comparison with
chlorpromazine. Archives of General Psychiatry 45:789796, 1988
49. Marder SR, Meibach RC: Risperidone in
the treatment of schizophrenia. American
Journal of Psychiatry 151:825835, 1994
50. Meltzer HY, Fibiger HC: Olanzapine: a
new atypical antipsychotic drug. Neuropsychopharmacology 14:8385, 1996
51. Small JG, Hirsch SR, Arvanitis LA, et al:
Quetiapine in patients with schizophrenia.
Archives of General Psychiatry 54:549557,
1997
52. Thomas CS, Lewis CS: Which atypical antipsychotic (editl)? British Journal of Psychiatry 172:106109, 1998
53. Glazer WM, Johnstone BM: Pharmacoeconomic evaluation of antipsychotic therapy
for schizophrenia. Journal of Clinical Psychiatry 58(suppl 10):5054, 1997
54. Keks NA: Impact of newer antipsychotics
on outcomes in schizophrenia. Clinical
Therapeutics 19:148158, 1997
55. Droge JA, Billig N: Improving practicing
physicians knowledge of geriatric mental
health issues. Family Medicine 24:158

160, 1992
56. Lebowitz BD, Rudorfer MV: Treatment research at the millennium: from efficacy to
effectiveness (editl). Journal of Clinical
Psychopharmacology 18:1, 1998
57. Patterson TL, Jeste DV: The potential impact of the baby-boom generation on substance abuse among elderly persons. Psychiatric Services 50:11841188, 1999
58. National Bioethics Advisory Commission:
Research involving persons with mental
disorders that may affect decision making
capacity, 1999. Available at http://bioethics.
gov/capacity/TOC.htm
59. Weiss R: Bioethics group divided over research on mentally ill. Washington Post,
Nov 16, 1998, p A6
60. Rowe JW, Kahn RL: Successful aging.
Gerontologist 37:433440, 1997
61. Symonds LL, Gladsjo JA, Heaton RK, et al:
Patterns of successful neurocognitive aging
(abstr). Journal of the International Neuropsychological Society 4:72, 1998
62. Harris HW, Lebowitz BD: Clinically oriented basic science: emerging opportunities for research in late-life mental disorders (editl). American Journal of Geriatric
Psychiatry 5:284286, 1998
63. Hill D: Electroencephalogram in schizophrenia, in Schizophrenia: Somatic Aspects. Edited by Richter D. New York,
Pergamon, 1957
64. Lindamer LA, Lohr JB, Harris MJ, et al:
Gender, estrogen, and schizophrenia. Psychopharmacology Bulletin 33:221228,
1997

38. DeLisi LE: The significance of age of onset

for schizophrenia. Schizophrenia Bulletin
18:209215, 1992
39. Jeste DV, McAdams LA, Palmer BW, et al:
Relationship of neuropsychological and
MRI measures with age of onset of schizophrenia. Acta Psychiatrica Scandinavica
98:156164, 1998
40. Jeste DV, Palmer BW, Harris MJ: Response
to Almeidas Early- versus late-onset schizophrenia: is it time to define the difference?
(ltr) American Journal of Geriatric Psychiatry 6:346347, 1998
41. Wasylenki DA: The cost of schizophrenia.
Canadian Journal of Psychiatry 39(9 suppl
2):S65S69, 1994
42. Wyatt RJ, Henter I, Leary MC, et al: An
economic evaluation of schizophrenia,
1991. Social Psychiatry and Psychiatric Epidemiology 30:196205, 1995
43. Cuffel BJ, Jeste DV, Halpain M, et al:
Treatment costs and use of community
mental health services for schizophrenia by
age-cohorts. American Journal of Psychiatry 153:870876, 1996
44. Population Projections of the United States
by Age, Sex, Race, and Hispanic Origin:
1995 to 2050. Washington, DC, US Bureau
of the Census, 1996

Reviewers Needed
Psychiatric Services seeks expert reviewers in the following areas:
Work with the police
Psychiatry in other countries
Experiences of patients and former patients
Telemedicine and telecommunications
Outcome and clinical measurement scales
Depot medications
Length of stay
Quality of life
Pregnancy and mental illness.
Reviewers should be familiar with the literature in
their areas of expertise, should have published in peerreviewed journals, and should be familiar with the content and focus of Psychiatric Services.
Prospective reviewers should send a curriculum vitae,
specifying areas of interest, to John A. Talbott, M.D.,
Editor, Psychiatric Services, APA, 1400 K Street, N.W.,
Washington, D.C. 20005 (e-mail, psjournal@psych.org).

45. Patterson TL, Kaplan RM, Grant I, et al:

Quality of well-being in late-life psychosis.
Psychiatry Research 63:169181, 1996

PSYCHIATRIC SERVICES

September 1999 Vol. 50 No. 9

1183