Harris Eyre, MD, PhD

 is a form of capitalism in which companies seek long-term value creation by taking into account the needs of all their stakeholders, and society at large.

 In order to ensure that individuals and the planet prosper, 4 key stakeholders play a crucial role: governments, civil society, companies, and the international community. In making the case against the maximization of shareholder value as a guiding principle, 

 argues that it is wrong to assume that the firm is a closed system, where only shareholders make investments in the productive assets, and hence only they have a claim on profits.

 Taxpayers, through the government agencies they fund, and workers, through their efforts, also make risky investments in firms’ productive capabilities. It follows that the state and labor have claims on profits if and when they occur.

We applaud this holistic model and believe it can do a better job prioritizing our brains—our most precious asset. Our brains are key to how we understand, navigate, and interact with our world, a world which is ever accelerating.

 We must be nimble, adaptable, and resilient to be successful in this modern world. Accelerating technological change requires agility and other 

 Various types of shocks (financial, climate, political, and viral) necessitate a flexible approach to the world and long-term resilience.

To synthesize these brain-based necessities, we recently proposed a new asset—brain capital, which prioritizes brain health and brain skills in the modern economy.

 Brain health challenges occur across the lifespan and include autism, depression, anxiety, and Alzheimer disease. They cost the global economy trillions per year, 

 And brain skills are critical not just to children and young adults, in their steepest learning curves, but to adults and older adults looking to stay engaged in a rapidly evolving workplace.

Science can help us understand how our behaviors and environments shape our brains. These insights can potentially guide policy and investing. Air pollution has been shown to 

 Easier access to forests, parks, and waterways has been shown to 

 The internet can stimulate learning and socializing which bolsters certain brain regions; however, there are downsides of the internet (eg, misinformation propagation, bullying, crime) which harm the brain. An emerging discipline is helping us understand the 

neuroscience of radicalization and extremism

 can lead to significant brain injuries for women and hence deficits in 

increase dementia-free years and longevity

 Poverty has long been known to damage brains across the lifespan, particularly poverty in early childhood.

We note a number of stakeholder capitalism-based initiatives that are prioritizing our brains. To provide a few examples, the Sustainability Accounting Standards board recently included mental health and wellbeing in its 

 gives guidance on managing psychological health and safety risks within an occupational health and safety management system.

 the generation of a healthy environment is a key purpose of a corporation.

 The signatories of the Principles of Responsible Investing recently listed mental health as one of the top 4 

 to Environment, Sustainability and Governance (ESG) investing around the world.

 The American Association of Retired Persons, the Organization for Economic Cooperation and Development (OECD), and the World Economic Forum have created a new interactive online platform, 

, to give employers the necessary tools, research, and resources to help them develop better practices to build their multigenerational workforce.

 Global pandemic response initiatives like COVAX, providing vaccines to the vulnerable in low- and middle-income countries, can protect brain capital of recipients by fending off the 

 Large public-private partnerships such as the 

, will help to develop new and desperately needed diagnostic and treatment innovations for sufferers of brain health disorders.

Initiatives which aim to support entrepreneur mental health may 

 of venture capital investment into the brain health technology space, along with a number of companies now considered 

 We also applaud the OECD for publishing the 

Recommendation on Responsible Innovation in Neurotechnology

, to cover opportunities and challenges for better innovation practices in company settings—including the use of ethics advisory boards, company-level principles, and ethics-by-design approaches.

We suggest a thorough approach when considering where and how to prioritize our minds and brains in the modern economy—brain-based stakeholder capitalism (see 

 Various types of investment instruments should be 

, such as impact investing, venture capital, and thematic exchange traded funds.

 Finally, we should work with economics and neuroscientists to 

track brain capital and impacts of these interventions

Figure. Brain-based Stakeholder Capitalism

Placing brain capital at the heart of economic development provides the opportunity to advance stakeholder capitalism. By prioritizing minds and brains, governments, civil society, companies, and the international community will be better equipped with health and skills needed to face unprecedented global challenges. Further, these stakeholders will be able to better develop the resilience and adaptability needed to navigate our modern world—enabling both people and the planet to thrive.

is a director with the PRODEO Institute and Thiel Fellow at Stanford University.

is a senior advisor to the Secretary General of the Organisation for Economic Co-operation and Development (OECD) and head of the New Approaches to Economic Challenges (NAEC) Unit.

is co-lead of the OECD Neuroscience-inspired Policy Initiative and holds adjunct roles with IMPACT at Deakin University, Baylor College of Medicine, the Global Brain Health Institute and BrainLat.

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https://www.weforum.org/agenda/2021/01/klaus-schwab-on-what-is-stakeholder-capitalism-history-relevance/

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https://www.uml.edu/fahss/economics/faculty/lazonick-william.aspx

Thank You for Being Late: An Optimist's Guide to Thriving in the Age of Accelerations.

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https://www.thersa.org/comment/2021/01/the-brain-economy

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8. Engermann K, Pedersen CB, Arge L, et al. Residential green space in childhood is associated with lower risk of psychiatric disorders from adolescence into adulthood. 

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https://www.unpri.org/pri-blog/covid-19-accelerates-esg-trends-global-investors-confirm/6372.article

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https://www.pionline.com/esg/global-esg-data-driven-assets-hit-405-trillion

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https://www.mckinsey.com/business-functions/strategy-and-corporate-finance/our-insights/from-principle-to-practice-making-stakeholder-capitalism-work?cid=app

Articles

By prioritizing minds and brains, governments, civil society, and companies will be better equipped with the health and skills needed to face unprecedented global challenges.

Modern Capitalism Must Prioritize Our Minds and Brains

The world is in the midst of an unfolding cognition crisis, with devastating personal, societal, and economic implications. The expanding elderly population requires better cognitive care; we are also coming to understand the importance of cognitive interventions and support in early childhood. Furthermore, the COVID-19 pandemic has brought global attention to cognitive issues, with over 50% of individuals recovering from the infection experiencing fatigue and brain fog. Initial studies indicate lasting deficits in executive function, impaired cognitive control, and reduction in global cognition leading to disability or reduced function.

 There are fears that COVID-induced deficits may last for years beyond the infection.

—such as attention, memory, perception, language, and reasoning

—are declining across the whole population. Beyond the effects of COVID-19, there is an alarming increase in the number of individuals around the world with serious cognitive impairments. These impairments co-occur with disorders including depression, anxiety, schizophrenia, autism, posttraumatic stress disorder, dyslexia, obsessive-compulsive disorder, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), addiction, dementias, and more.

 The severity, type, duration, and course of cognitive dysfunction differ between these disorders. The aging world population will heighten the cognition crisis. By 2060, the 

number of individuals aged 65 and older is projected to double

 is often only assessed when there is a specific, subjective complaint from patients, family members, or caregivers. In this context, there are many factors which suboptimize the value. For example, there are lengthy waiting lists to see neuropsychologists or cognitive neurologists, and various modalities used to assess cognitive dysfunction in later life are inaccessible to most (eg, positron emission tomography and advanced magnetic resonance imaging scans). Furthermore, there is no consistent clinical assessment algorithm for how to use cognitive assessment tools (eg, when to use pencil and paper tests, digital, blood-based, or neuroimaging). When there is no specific, subjective cognitive complaint, cognition is not assessed. This means more subtle and slow-onset forms of cognitive dysfunction may be missed. This can delay treatment and mean more progressive brain changes. If cognition is assessed, it is often not addressed, supported, or followed up in the long-term. Further, in many developing countries, cognition is rarely—if ever—screened, resulting in complications such as high rates of undiagnosed dementia.

 across the lifespan, it is critical that cognition is assessed and monitored across disorders and throughout life. Addressing and building cognition is especially crucial during early childhood, when cognitive difficulties can be caught before they have too much detrimental impact on a child’s developmental trajectory.

Examples of Cognitive Decline in Psychiatric Conditions

Consider depression: More than 264 million individuals around the world suffer from depression, making it the 

 and a major contributor to the overall global burden of disease.

 Depression is commonly associated with a lowering of a patient’s mood and energy for long periods of time. Depression also impairs cognition, including affecting attention, memory, information processing, decision-making skills, cognitive flexibility, and executive functioning.

 Indeed, 85 to 94% of individuals with acute depression experience significant cognitive impairments.

 Even when depression has remitted, around 40 to 45% of patients report dysfunction in one cognitive domain.

 Cognitive impairments are not addressed by first-line 

is now proposed as a novel treatment target for depression.

 Cognitive remediation therapy has provided encouraging results for the management of cognitive deficits in major depressive disorder (MDD).

 The incorporation of biobehavioral strategies (eg, exercise) and multimodal treatment approaches (eg, cognitive training, antidepressant therapy, and neuromodulation) is likely to generate therapeutic benefit.

Another example is cancer. It is estimated that at the end of 2020 there were over 70 million cancer survivors worldwide.

 Cognitive impairments—including deficits in visual working memory, sustained attention, new learning, and more—are commonly observed in patients with cancer and those in remission.

 Though cancer- and chemotherapy-related cognitive impairments (eg, confusion, lapses in memory and attention, difficulty concentrating, etc) are often known colloquially as chemo brain or chemo fog, up to 30% of patients with cancer exhibit subtle cognitive impairments prior to treatment, suggesting the body’s physiological response to a tumor (eg, inflammatory processes or vascular changes around the tumor) may be disruptive to cognition.

 Neuroimaging and neuropsychological studies have validated the role of chemotherapy contributing to cognitive issues, with chemotherapy patients having a more difficult time during memory recall than those cancer patients who did not receive the drugs, which suggests that their neural networks had been altered.

 Indeed, 75% of cancer patients have cognitive impairments during treatment, and 35% of survivors have cognitive impairments that continue in the months and years after treatment.

In addition to depression and cancer, there are many other disorders across the lifespan that have been shown to cause cognitive impairments, including ADHD,

 chronic obstructive pulmonary disease (COPD),

 depicts a small subset of disorders with associated cognitive problems.

Figure 1: Subset of Disorders With Associated Cognitive Impairments33

Innovative measurement-based approaches need to be leveraged to better understand and treat the impacts of cognitive impairments from disorders across the lifespan. Measurement-based care can be defined as the practice of basing clinical care on client data collected throughout treatment. Measurement-based cognitive care, therefore, includes ensuring that cognition is assessed and monitored at all stages of the treatment process across a multitude of disorders—not merely Alzheimer disease (AD) and late-life cognitive decline.

For example, with cancer patients, cognition needs to be assessed before treatment begins and then regularly during and after treatment. Cognitive assessments must also be easy for the patient to access. Since these patients will already be saturated with physical and mental health interventions, it is critical that any cognitive assessments and additional interventions are able to fit into their lives as seamlessly as possible.

Regular assessment and monitoring of cognitive health is also critical across the entire spectrum of health, including those who do not have a present health concern. Innovative delivery systems—such as at-home digital technologies—can ensure accessibility and awareness that these assessments exist. Regularly assessing cognition throughout the lifespan will enable cognition to be used as a new vital sign. Further, it will provide the opportunity to establish an individual’s cognitive baseline; identify changes that may suggest prodromal stages of disease and allow for early intervention. Cognitive care will adopt a more proactive, preventative, and personalized approach to one’s cognitive lifespan. Psychometric quality is clearly critical (ie, robust assessments of performance norms, reliability, validity, sensitivity, and specificity).

 Ensuring cognitive assessments include quality of life and activities of daily living is also important. 

New technologies and tools will help make measurement-based cognitive care a reality. New, predictive tools in cognition include 

 Tracking eye-movement has been found to offer a window into cognitive processes and impairments. Preliminary data indicate that eye-tracking tests may detect early stages of AD

; characterize cognitive impairments in patients with other neurological disorders, including amyotrophic lateral sclerosis, Parkinson disease, multiple sclerosis, autism spectrum disorders,

; and identify and access brain dysfunction in patients—including children—with mental health conditions such as depression.

 When implemented in a digital setting, some novel tools have been found to have a myriad of benefits.

For example, Akili Interactive developed the first and only 

 that has been cleared by the US Food and Drug Administration to treat adolescent ADHD and improves attention impairments.

 Akili’s digital therapeutic for adolescent ADHD has been found to improve objectively measured inattention as determined by the Test of Variable Attention Attention Performance Index (API) in adolescent patients with ADHD.

 Other digital therapeutics have been found to reduce cognitive impairments in adults living with MDD

 Tools are also being developed to promote the development of cognitive skills during childhood.

 Some smart phone-based technologies may be deployed worldwide including to low- and middle-income countries, allowing greater equity in cognitive care.

The necessity of validated remote evaluations—enabled by many of these new biomarkers—is apparent, underscored by the recent limitations on in-person visits secondary to the COVID-19 pandemic. Digital technologies are well positioned for a role in remote evaluation to be used synchronously or asynchronously and over telemedicine platforms.

We must re-engineer the modern health care team when moving towards measurement-based cognitive care. Just as genetic counselling was established as a new field in 1969 to help individuals navigate genetic risk and testing, a new field needs to be established to help patients navigate cognitive risk and testing. Many new cognition biomarkers provide a risk score or predictive analytic, which like predictive genetics can bring a host of new questions and worries: What does my score mean? How do you interpret a black-box algorithm? What can I do about my risk for cognitive impairment after chemotherapy? Am I developing AD or am I experiencing cognitive problems due to depression? Will these results create issues for my health or life insurance policies?

Cognition counselors are needed as part of the modern care team to 1) ensure that cognition is addressed in disorders where it is commonly overlooked (eg, postsurgery, cancer, diabetes, depression, etc); 2) help patients navigate the new anxieties and questions that arise from new technologies, cognitive assessment, and risk scores; and 3) discuss and coordinate care options and provide referrals to educational services, advocacy and support groups, novel technologies, other health professionals, and community or state services. Cognition counselors will also help overcome the barriers of implementing digital technology in both a clinical and educational setting, increasing acceptance and compliance. Further, existing care team members—such as clinical neuropsychologists—could also be trained or upskilled to fulfill the role of cognition counselors, helping to rethink and 

To optimize the likelihood that measurement-based cognitive care can be instituted, leveraged tools should be brief (≤ 10 minutes), highly scalable, able to be administered by the patient or trained clinical staff, and able to automatically generate an interpretative report with instant electronic medical record integration.

 To further help realize measurement-based cognitive care, health systems must be prepared to move quickly when a new biomarker is seen to add clinical value. We applaud the work of the 

 for proposed frameworks to accelerate such preparedness.

Finally, design thinking principles must be strictly adhered to in the development of novel biomarkers given these tools can be deployed across disorder type and the lifespan.

 For example, elderly individuals may experience changes and challenges that span disability segments, including visual, cognitive, speech, mobility, and neural impairments. From deterioration in vision to difficulty touching screens to everything in between, novel biomarkers and tools must account for these changes and be designed to be accessible to all. The fields of disability studies and assistive technologies will likely be 

 Further, measures must be taken to mitigate practice effects from repeated use of measurement-based cognitive care tools, ensuring that increasing familiarity and exposure to cognitive tests does not become a confounding factor in scores.

Measurement-based cognitive care is the urgently needed to address to the unfolding cognition crisis. Measurement-based cognitive care will bring an era of medicine where cognition is proactively addressed and better understood for disorders across the lifespan; technologies and tools underpin advancements in cognitive assessment and monitoring; and care teams are equipped to help patients navigate the new uncertainties that arise and receive proper care. In doing so, individuals will be able to improve their quality of life and have their capacity to thrive increased. Placing measurement-based cognitive care as a critical component of medicine will bring widespread personal, medical, and societal benefits.

a member of the Steering Committee of the Organization for Economic Co-operation and Development (OECD)-PRODEO Institute Neuroscience-inspired Policy Initiative, and an Atlantic Fellow for Brain Equity at the Global Brain Health Institute at UC San Francisco (UCSF).

Joy Chambers-Grundy Professor of Brain Science and Director of the Chambers-Grundy Center for Transformative Neuroscience, University of Nevada Las Vegas (UNLV).

is a Professor in Cognitive Neuroscience and Director of Research in the Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Australia.

T. Boone Pickens Distinguished Scientist at the Center for BrainHealth, a codirector at Global Brain Health Institute, professor emeritus at Trinity College Dublin, and founding director of its Institute of Neuroscience.

a Senior Clinical Advisor for Cohen Veterans Bioscience’s Trauma Research Programs. She serves as Strategic Advisor co-leading CVB’s Suicide Strategy Initiative.

Turner Institute for Brain and Mental Health, Neurodevelopment Program School of Psychological Sciences, Monash University.

is the professor of psychiatry, Director, Late-life Mood, Stress and Wellness, and Integrative Psychiatry research programs UCLA Semel Institute for Neuroscience and Human Behavior.

cofounder of the PRODEO Institute, co-lead of the OECD-PRODEO Institute Neuroscience-inspired Policy Initiative,

instructor in brain health diplomacy at the Global Brain Health Institute. He holds adjunct positions with IMPACT at Deakin University and Baylor College of Medicine.

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Textbook of Clinical Neurology, Volume 355

The Distracted Mind: Ancient Brains in a High-Tech World

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The world is facing a cognition crisis. Here’s how to face it with measurement-based cognitive care.

Harris Eyre, MD, PhD

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Modern Capitalism Must Prioritize Our Minds and Brains

Addressing the Cognition Crisis in Our COVID-19 World

Buyer Beware: Why Investors and Mental Health Practitioners Must Sit on the Same Side of the Table

Boosting Brain Health After COVID-19: A Convergence Solution

Highlighting Brain-Based Inequalities for Women: From Bedside and Boardroom to Policy

Our Brains Are Accelerating the Climate Catastrophe

A Brainier Approach to ESG Investing

Feeling Lucky? Convergence Mental Health as a Mechanism for Serendipitous Innovation

Smart Growth: the Case for Measuring Brain Capital

Move Over Data, Brain Capital is the New Oil