Helen Lavretsky, MD, MS

Society’s psychological reactions to a crisis can be predicted according to disaster response frameworks. Mental health innovators can use these frameworks to understand what to build during the evolving 

 crisis, and when those innovations will prove most vital.


	While the occurrence of disasters is largely unpredictable, the human emotional response to disasters is relatively predictable. Researchers have mapped the phases of emotional 

 based on patterns that have been consistently witnessed in times of crisis, from hurricanes to terrorism to disease.

 Although plot details differ, the same storyline can be applied to crises worldwide: the impact occurs, heroism abounds, social cohesion surges, and then, once the news crews have resided, another sentiment takes its place-disillusionment, apathy, grief, and psychological distress.

Crisis, however, does not have to be an inhibitor of innovation, but can be an invitation for innovation. Historically speaking, crisis is often followed by a creative resurgence of the human spirit that guides changes in technological and social innovation, like the 

 (1347-1350), which was soon followed by the Italian Renaissance; new societal concepts and financial institutions can bring about global restructuring that facilitates psychological adaptation and growth (similar to the concept of post-traumatic growth). We witnessed this in the last global crisis, World War II, that resulted in the complete remake of the world’s social matrix with the emergence of the US as the global leader, and significant innovations on every level of human functioning.

While facing the reality of the COVID-19 pandemic, we can anticipate far-reaching consequences that will affect our financial system in the immediate future and bring about massive changes to the way our world functions on every level. This global pause-the “quarantine”- as a self-imposed reset button has the opportunity to usher in a heightened awareness of our individual priorities, and a burst of alternative technological solutions that are likely to persist beyond the viral pandemic, such as how schools and education function, or how health care is administered.

In light of the COVID-19 crisis, we can use this historical precedent-now conveniently captured by emotional response disaster frameworks-to guide our path forward. Not only can these frameworks be used to understand how and when our world will be psychologically affected by this disaster, but they can help inform what is needed during each phase to best support mental, emotional, and spiritual well-being. Mental health innovators must come to view their work through a public health lens, not only considering what is immediately needed, but what needs will arise once the “honeymoon” phase of this crisis is over.


	Over the course of March 2020, our world traversed the heroic phase of the disaster response. This phase is characterized by high levels of activity, low levels of productivity, and a surge in altruistic, adrenaline-induced rescue behavior (think: health care providers valiantly working without personal protective equipment).

 During this phase, the mental health innovation trend was that of open-access innovations. A multitude of companies, from meditation apps to teleconferencing technologies, offered free or discounted access to their platforms in this time of limited resources and millions out of work. Examples of this include therapy app Talkspace, which now offers free therapy for health care workers and discounted subscriptions for the public, and the meditation app Headspace, which now offers free meditation recordings for all.
	• Phase: Heroic - March 2020
	• Characteristics: High activity, high altruism, low productivity
	• Innovation trend: Open-access

Throughout April 2020, we entered the honeymoon phase (

). In this phase, disaster assistance became available, community bonding was more prevalent than ever (albeit virtual), and there was a sense of collective optimism.

 This honeymoon phase seems to be characterized by the mental health innovation trend of platform innovations-the use of existing technologies (apps, websites, etc) upon which new products and services can be offered. Examples of this include the teleconferencing platform Zoom, which has created specialized resources, tools, and capabilities to meet the heightened demand and unique needs of this time; Facebook helping local governments and emergency health organizations reach people via Facebook and Messenger.
	• Phase: Honeymoon - April 2020
	• Characteristics: High assistance, high bonding, high optimism
	• Innovation trend: Platform


	However, as we move deeper into May 2020 we seem to be nearing a less hospitable phase-the disillusionment phase (

). In this phase, the public has recognized the limits of the governments in being able to control viral spread, develop vaccines, or provide disaster assistance. We are feeling a heightened sense of discouragement and distress as we see more clinical manifestations of reactions to stress including affective and emotional symptoms (anxiety, phobias, depression, irritability, apathy, withdrawal); physiological disorders, sleep disorders and dreaming disturbances, memory disorders; behaviors that reinforce and maintain the trauma in the conscience; and 

 Experts have been referring to this phase as the “mental health tsunami”-if the virus outbreak was the earthquake, then mental illness will be the storm surge that comes in its wake. In the disillusionment phase, realities like unemployment, debt, and death begin to sink in, and individuals may rely more heavily on alcohol, opioids, and the like to cope.

Disillusionment is the longest of the phases-the depth of which will largely dictate how quickly and easily we will recover-which is why it will need to be characterized by a mental health innovation trend of prevention innovation. These technologies must focus on the prevention or mitigation of mental health issues like depression, 

, and addiction, as it is through prevention that we will lessen the depth of the post-crisis crash. An example of an existing prevention technology is affective computing that can detect depression relapse or emergent suicidal ideations through the wearable devices or iPhone use, and connect individuals to mental health providers.

 can assist in detecting high-risk populations among health care workers who might be experiencing burn out, stressed caregivers, or students with high levels of pre-existing anxiety. Technologies oriented toward rebalancing of stress response (eg, meditation and breathing apps, music and art therapy, promoting sleep, proper nutrition, and facilitating immune response) could be developed to guide those in distress.
	• Phase: Disillusionment (including post-crisis crash) - May 2020 - ?
	• Characteristics: Low optimism, high distress, high illness
	• Innovation trend: Prevention


	Although we cannot say for certain how long the disillusionment phase will last-the range is from months to years, especially with the looming financial crisis-we will eventually emerge into the calmer waters of the reconstruction phase.

 During this phase, individuals feel a sense of recovery, responsibility, and capacity for rebuilding-there is a greater acceptance of and adjustment to the new normal. With the new normal must come novel solutions, which is why mental health innovation will need to be characterized by frontier innovations, novel technologies based on significant scientific advances, and engineering innovation. Examples of frontier technologies include innovations like AI, sensors, -omics, imaging, synthetic biology, smart devices, digital therapeutics, and the like. While this is not to suggest that frontier technologies should not be built throughout the crisis, it’s also useful for mental health innovators to consider what tools are most crucial and when they are most needed. For instance, frontier technologies may not be readily adopted during the disillusionment phase if they are too costly or complex to use during a time of great uncertainty.
	• Phase: Reconstruction - timing unknown
	• Characteristics: Return to recovery and responsibility
	• Innovation trend: Frontier

Although these stages of response to disasters are true for the population at large, patients with serious mental illness are more vulnerable to profound levels of depression, anxiety, and distress, and may not reach recovery without additional help from practitioners.


	The COVID-19 pandemic is forcing us to face the reality that our world has shifted-climate change, natural disasters, and pandemics are part of our new normal. What seemed stable is now uncertain, our hope in the government’s ability to manage all disasters is diminishing, and we are turning to each other and to our neighbors for solutions. The phrase “we are in this together” rings true for us and has left us to ask: What can each of us do to contribute to the solution and solvency of our society and the planet 

? How can we innovate to continue to enjoy our planet, and leave it to our children to enjoy and develop further? What should be guiding the development of technologies during crises of global proportions such as COVID-19?

To guide innovation at every level, we should anticipate the spiritual and psychological needs of the population at large, as well as those of the most vulnerable patients. Maintaining hope, focusing on well-being, and rebalancing the stress response, as well as improving infrastructure for mental health care can help reduce burnout in the health care workforce and improve the lives of all individuals. We encourage you to consider the following questions with us:
	1. How can we inspire, encourage, and retrain those who have been cast aside as “non-essential” in this time? If retraining 20 million people can be quickly achieved, what scalable technological or vocational training can be offered immediately?
	2. In an increasingly non-religious world, what scalable spiritual alternatives can be offered to provide individuals with answers to existential questions like meaning, purpose, destiny, control, and role of the self at this time?
	3. How can we cultivate resilience to ensure society of its capacity to rebuild and redesign our collective new normal?


	4. How can we train individuals to live simpler lives with enhanced self-reliance, and how can technological innovation help?

Armed with the knowledge of the human emotional response to disaster, we can anticipate and potentially bypass psychological lows by preparing humanity to be more flexible, proactively deal with disasters, and honor their own strength and ability to fight adversity. Mental health innovators will represent a group of humble, perhaps unsung heroes in this crisis, and it’s through collaboration, urgency, optimism, and trust that we will get through this together.

 It’s time for us to get to work-to help, heal, and harness the innovative potential inherent in crisis.

, Expert in Residence at Georgetown University, and author of Wired This Way; 

 is Brain Health Venture Executive and Innovation Diplomat, Instructor in Entrepreneurship at the Global Brain Health Institute (UCSF and Trinity College Dublin), Advisor to Brainstorm Lab for Mental Health Innovation, Stanford University, Honorary Fellow with IMPACT, Deakin University, Australia; 

 is Professor of Psychiatry, Department of Psychiatry, University of California Los Angeles. We’d like to hear from you, you can email Jessica Carson (jessica@jessicacarson.co), Harris Eyre (harris.eyre@gmail.com), or Helen Lavretsky (hlavrets@ucla.edu) with questions, comments, or if you’d like more information on mental health innovation ideas. The authors report no conflicts on interest concerning the subject matter of this article.

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Dealing with Stress, Anxiety, and Grief during COVID-19

Articles

Society’s psychological reactions to a crisis can be predicted according to disaster response frameworks, which can be used to understand what to build during the evolving COVID-19 crisis, and when those innovations will prove most vital.

Dear Mental Health Innovators: The COVID-19 Honeymoon Is Almost Over

Dr. Lavretsky is Professor of Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles.

This Special Report on Geriatric Psychiatry addresses a variety of clinical issues in the rapidly growing diverse population of older adults. With the increase in the population of adults over age 65 years expected to reach 22% of the general population by 2040, neuropsychiatric disorders of aging will become a challenge for many practicing health care providers. This demographic trend has led to an intensive search for effective strategies to diagnose, treat, and prevent mental, cognitive, and physical disorders of aging.

The stigma of mental illness still overshadows proper diagnosis and management of neuropsychiatric symptoms and disorders in the elderly. The boundaries between neuropsychiatric and physical illnesses are often blurred, especially in the acute medical and in long-term care settings, because of frequently comorbid mood, anxiety, cognitive, and physical disorders in older adults. Aging-related physiological changes lead to the increased risk of adverse events such as falls and drug toxicity with pharmacological management.

The growing population of aging baby boomers brings to light new challenges characteristic of this cohort, such as increasing rates of drug abuse and higher rates of depression and anxiety, sleep disorders, and PTSD compared with previous generations. The issue of gender identity and the aging LGBTQ community is coming to the forefront of public and professional awareness of the unique health care needs of its members. It is also becoming more obvious that multiple diseases of aging share common risk factors and may benefit from shared treatment and preventive strategies, such as heart disease, diabetes, and Alzheimer disease.

The 7 articles in this section highlight common clinical dilemmas and outline the nuances of diagnosis, management, and outcomes-and provide helpful practical tips for clinicians. We hope that readers will find the information in this Special Report clinically relevant and helpful in the diagnosis and treatment of neuropsychiatric conditions in older adults.

Dr. Lavretsky reports that she has received research grants from Forest/Allergan.

This work was supported by the NIH grants MH97892, AT009198, and AT008383.

This Special Report on Geriatric Psychiatry addresses a variety of clinical issues in the rapidly growing diverse population of older adults.

Introduction: Neuropsychiatric Disorders of Aging

Meet Helen Lavretsky, Professor of Psychiatry at UCLA, who speaks about a 

 in older adults with subjective memory complaints and mild cognitive impairment.

Patients assigned to yoga practice for 12 weeks with daily meditation for 12 minutes in weekly one hour classes did better than those who participated in memory training classes in verbal and visual memory, executive function, mood resilience, anxiety, and connectivity of the brain.

Results suggest that yoga can be a cognitive enhancement or brain fitness exercise that can confer similar or even more extensive cognitive resilience than memory training-the gold standard-in older adults.

Meditation in this study was practiced with music recorded on the 

 album, which received a Grammy award this year.

Dr Lavretsky is Professor of Psychiatry at UCLA. She also directs the Late Life Mood, Stress, and Wellness Research Program at the Semel Institute at UCLA. She is a member of the Editorial Board of 


	
	1.Eyre HA1, Siddarth P1, Acevedo B1, et al. A randomized controlled trial of Kundalini yoga in mild cognitive impairment. 

https://www.cambridge.org/core/journals/international-psychogeriatrics/article/randomized-controlled-trial-of-kundalini-yoga-in-mild-cognitive-impairment/138A3EB97520CE72B01D17059B7AA286

.
	
	2. Yang H, Leaver AM, Siddarth P, et al. Neurochemical and Neuroanatomical Plasticity Following Memory Training and Yoga Interventions in Older Adults with Mild Cognitive Impairment. 

 http://journal.frontiersin.org/article/10.3389/fnagi.2016.00277/full

In this pilot study, older adults who practiced yoga did better on measures of verbal and visual memory and executive function than those in memory training classes.

Cognitive Enhancement-With Yoga

Dementia, also referred to as major neurocognitive disorder (including Alzheimer disease [AD]), is a growing problem because of increased lifespan. There is no known cure. Several drugs are FDA-approved for the treatment of dementia, including acetylcholinesterase inhibitors (eg, donepezil, rivastigmine, galantamine) and an 

-methyl-D-aspartate (NMDA) receptor antagonist, but these have limited efficacy, adverse effects, and significant cost-all of which contribute to the search for alternative therapies to improve cognition.

In this article, we look at several natural products used to improve cognitive impairment or cognitive symptoms of dementia (

A popular supplement for cognition is ginkgo biloba, which is extracted from the leaf of the Maidenhair tree. Although it has been used as a supplement in the US, in many European countries it is part of mainstream medical care and requires a prescription. A standardized extract called EGb 761 is prescribed in many countries outside of the US.

 examined the mechanisms of ginkgo biloba that provide neurocognitive benefits and defined its 3 main active agents: ginkgolides, bilobalide, and flavonoids. The ginkgolides are thought to inhibit platelet-activating factor, thereby preventing clotting, promoting blood flow, and inhibiting inflammatory mediators such as cyclooxygenase-2, nitric oxide synthase, and tumor necrosis factor. Bilobalide is thought to inhibit platelet-activating factor receptors and

9 Natural Supplements for Cognitive Impairment

reduce the excitotoxic effects of glutamate. Finally, the flavonoids serve as antioxidants that reduce the damage caused by free radicals.

The majority of trials that show the benefits of ginkgo biloba pertain to improved cognition in persons who already have a major neurocognitive disorder or dementia. However, the data regarding a benefit in cognitively intact individuals are mixed. The most rigorous study by Mix and Crews

 examined the effect of a 180-mg dose of ginkgo biloba on community-dwelling individuals without neurocognitive disorders. Full neuropsychological testing showed some small improvements in memory, but intergroup differences limited the results. The dosage was lower than typically recommended, which is generally about 120 mg to 240 mg, 2 or 3 times daily. Another randomized clinical trial (RCT), which used a 240-mg dose of ginkgo biloba, demonstrated some small effects in immediate and delayed recall.

 In summary, there is no compelling evidence to support the use of ginkgo biloba to improve memory functioning in individuals who are cognitively intact.

Can ginkgo biloba prevent major neurocognitive impairment? Four well-designed studies show differing results. The Ginkgo Evaluation of Memory (GEM) study examined more than 3000 individuals aged over 75 years with either normal cognition or mild cognitive impairment.

 The study failed to show any protective effect of ginkgo biloba in preventing dementia.

Another study looked at the prevention of AD in adults aged 72 to 96 years with either normal cognition or mild cognitive impairment.

 The study used EGb 761 (a ginkgo biloba extract) at a dosage of 120 mg twice daily over the course of 6 years. No risk reduction was found.

The GuidAge study looked at the prevention of dementia with ginkgo biloba in more than 2000 community-dwelling older adults over a 5-year period.

 Like the GEM study, the GuidAge study did not show a benefit of ginkgo biloba in preventing dementia over 4 years; however, after 5 years, it started to show an improvement. A limitation of the GuidAge study is the especially low incidence of dementia in the participant population (1.2/100 to 1.4/100), which makes it more difficult to show statistical significance. The large, 20-year PAQUID study showed that ginkgo biloba prevented dementia. However, important characteristics such as dosage and duration of ginkgo treatment were not documented.

These studies include both epidemiological studies as well as RCTs, which make it difficult to compare findings. Epidemiological studies do not control for confounding variables, such as comorbid risk factors that might contribute to the development of dementia. Moreover, there is insufficient evidence to support the use of ginkgo biloba in the prevention of dementia. Studies that focus on dosage and duration of ginkgo biloba administration are needed to remove the potential confounding effects.

Some evidence supports the use of ginkgo biloba in those already affected by a major neurocognitive disorder. Thus, given that more traditional agents do not generally show superiority, ginkgo biloba is a reasonable option for such patients. The data on ginkgo biloba for improving cognition in patients with dementia are more extensive than the data on prevention of cognitive impairment. Birks and Grimley Evans

 evaluated 36 trials on the effects of ginkgo biloba on cognition in persons with cognitive impairment and determined that the results were inconsistent, although they noted that ginkgo biloba is fairly safe.

A smaller but more recent meta-analysis demonstrated a potential benefit of ginkgo biloba on cognition in those who already had cognitive impairment.

 The standard mean difference calculated between ginkgo biloba and placebo was -0.89 (95% confidence interval, -1.82 to 0.04), and there was a statistically significant but not necessarily clinically significant benefit on Alzheimer Disease Assessment Scale-cognitive (ADAS-cog) scores of 2.65. Significant improvement in cognitive functioning in outpatients with mild to moderate AD or vascular dementia occurred with 240 mg of EGb 761.

 In addition, ginkgo biloba has an antidepressant effect in patients with dementia.

 Other studies have shown that ginkgo biloba was not inferior to donepezil and may provide added benefit when both are given to individuals with AD.

Ginkgo biloba must be used with caution in patients who are at increased risk for hemorrhage because it may potentiate bleeding. However, studies of its effect on bleeding function found ginkgo biloba to be safe alone and in combination with antiplatelet drugs.

Persons who are most likely to benefit from ginkgo biloba include those who already have dementia.

 identified omega-3 fatty acids as one of the most common complementary and alternative medicines. Nutritional sources of omega-3 fatty acids are primarily fish, nuts, algae, and krill. The 2 main forms of omega-3 fatty acids are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). DHAs are important in neuronal development; DHA deficiency increases the risk of developmental delays.

 Beyond neurodevelopmental effects, omega-3 fatty acids may serve a neuroprotective role through antioxidant, anti-inflammatory, and antiamyloid effects.

 the consumption of fish reduced the development of AD. In APOE-4 non-carriers, eating fish 2 or 3 times per week reduced the development of dementia by 50% over 4 years.

 In a prospective follow-up study, 899 individuals without dementia were studied over 9 years. There was a 47% reduction in the development of AD in participants with high plasma levels of DHA.

Supplementation with omega-3 fatty acids has been less promising than the consumption of fish. A meta-analysis showed that omega-3 fatty acid supplementation is helpful for mild cognitive impairment but not for dementia or prevention of dementia.

 Both attention and processing speed improved with supplementation.

The APOE-4 allele is a genetic predisposition for the development of AD. Individuals who have this genetic susceptibility to AD do not appear to benefit in the same way from omega-3 fatty acid supplementation as do individuals without the APOE-4 allele. Older adults who seek to prevent AD might benefit from a diet rich in omega-3 fatty acids, including fish; whereas older adults who already have mild cognitive impairment might benefit from omega-3 fatty acid supplementation to improve attention and memory.

Omega-3 fatty acid supplements, primarily EPA, also provide an antidepressant effect.

 Thus, it is possible that supplementation for the purpose of cognitive impairment might have unforeseen benefits on mood. Similarly, the confounding effect of omega-3 fatty acids might be improved cognition with the improvement of depression, since depression in geriatric patients often adversely affects cognition.

Ginseng may have cognitive-enhancing effects. In a study that compared Korean red ginseng with placebo, significant improvement was seen in ADAS-cog scores in participants who received 9 g of ginseng.

 Another study used 150 mg of Panax ginseng as well as other cognitive-enhancing agents, including 120 mg of ginkgo biloba and royal jelly.

 Statistically significant improvement in cognitive function was observed, as measured by about 2 points on the Mini-Mental State Examination (MMSE); however, such improvement is not always considered clinically significant.

Huperzine A is a bioactive constituent of 

, which has been suggested to have cognitive-enhancing effects. Huperzine has several mechanisms of action similar to those of traditional cognitive-enhancing medications, such as acetyl cholinesterase inhibitors, and the antagonistic effects on the NMDA receptor. The common dose range is from 200 to 400 µg.

An RCT showed an improvement in activities of daily living with 100 µg of huperzine twice daily.

 However, a larger US study demonstrated less significant effects. The study compared 200 µg and 400 µg of huperzine twice daily. A modest effect on cognition was observed with 400 µg of huperzine in patients with AD.

 The most common adverse effect of huperzine is nausea. For individuals with dementia who cannot tolerate or afford traditional cognitive-enhancing medications, huperzine may be an effective alternative.

Deficiencies in cyanocobalamin (vitamin B

) can cause cognitive impairment. Therefore, it is standard practice to evaluate levels of these vitamins in anyone who presents with cognitive impairment.

, as evidenced by elevations in methylmalonate and homocysteine, are related to deficiencies in memory and decreases in perceptual speed and brain volume.

Data do not support a cognitive-enhancing effect in individuals with normal vitamin B levels.

 The doses of vitamin supplements in the study were 5 mg of folate, 25 mg of vitamin B

; the duration of treatment was 18 months. Another study that included individuals older than 60 years with AD or vascular dementia and normal vitamin B levels also failed to show a therapeutic effect with vitamin B supplementation.

 may have a cognitive-enhancing effect in persons with normal cognition. Therapeutic benefits on immediate and delayed recall were observed with vitamin B supplementation in adults aged 60 to 74 years.

 Although there is insufficient evidence to show the benefit of vitamin B supplementation on cognition in persons with dementia and normal vitamin B levels, the data suggest some benefit in cognitively intact individuals. Adverse effects include induction of mania and burning sensations.

Vitamin D stimulates macrophage-induced phagocytosis of beta-amyloid protein.

 In a population study of 171 individuals, an increased incidence of all-cause dementia was seen in those who had vitamin D deficiency compared with those who had normal levels.

Beyond cognition, vitamin D appears to have a therapeutic window to strive for in optimizing treatment. Optimal levels of vitamin D (25-hydroxyvitamin D) are greater than 25 nmol/L and less than 50 nmol/L. Michaelsson and colleagues

 reported increased mortality related to low vitamin D levels (< 46 nmol/L) and high vitamin D levels (> 98 nmol/L). An RCT of older women who had normal vitamin D levels demonstrated an increased risk of falls and fractures when participants were given a large bolus of vitamin D.

 High levels of vitamin D (> 56 mmol/L) also increase mortality risk.

Coconut oil is a medium-chain fatty acid that is more easily digested than saturated fatty acids identified as long-chain fatty acids.

 There is limited evidence to support the use of coconut oil for AD. Most of the evidence comes from the Newport Story, which consists of robust effects in a case study of a male with AD.

Coconut oil is hypothesized to have numerous beneficial effects, which might indirectly reduce the risk of AD. Several mechanisms may be implicated, including its antioxidant effect; moreover, coconut oil reduces accumulation of beta-amyloid and lowers insulin resistance and low-density lipoprotein cholesterol.

There is more evidence to support caprylidene (Axona), which is a derivative of coconut oil and consists of medium-chain fatty acids. The theory behind caprylidene is based on hypometabolism of glucose in the brains of patients with AD. Caprylidene creates a state of ketosis that provides an alternative energy source for the neurons.

 Patients with mild to moderate AD who received caprylidene showed an average improvement in ADAS-cog scores of 1.533 points after 45 days. It is important to note that this improvement was observed only in those who were non–APOE-4 allele carriers and that many of the individuals were taking cognitive-enhancing medications (acetylcholinesterase inhibitors or memantine) as well as caprylidene.

Coconut oil and its derivative caprylidene have limited adverse effects. The most common include gastrointestinal effects, such as diarrhea, flatulence, and dyspepsia.

Although there is insufficient evidence to recommend either resveratrol or curcumin in preventing or treating cognitive impairment, the 2 supplements hold promise in improving cognition. A phase 2 RCT with resveratrol did not demonstrate significant changes in cognition as measured by MMSE or ADAS, but it did show an increase in cerebrospinal fluid levels of amyloid beta, a biomarker of AD.

There have also been some positive results with curcumin. A study by Baum and collegues

 showed good tolerability but did not detect a cognitive-enhancing effect. In cognitively intact individuals, curcumin reduced triglyceride levels as well as plasma beta-amyloid levels.

Multiple agents are marketed for cognitive impairment; however, few have compelling evidence to recommend their use in vulnerable populations. More data are needed to better understand these potential treatments for cognitive impairment. Ideally, larger, better-designed studies with multiple dosing would benefit our understanding as well as studies that help identify the specific mechanism of action of the various complementary and alternative medicines.

Dr. Varteresian is MH Psychiatrist, Los Angeles County Department of Mental Health, and Assistant Clinical Professor (volunteer) at the University of California, Irvine. Dr. Lavretsky is Professor of Psychiatry at the University of California, Los Angeles (UCLA) and Director of the Late-Life Mood, Stress, and Wellness Research Program at the Semel Institute for Neuroscience and Human Behavior, Geffen School of Medicine at UCLA. Dr. Varteresian reports no conflicts of interest concerning the subject matter of this article; Dr. Lavretsky reports that she is a recipient of grants from Forest Research Institute/Actavis and the NICCIN and NIMH.

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Here: a look at several natural products used to improve cognitive impairment or cognitive symptoms of dementia.

Natural Supplements and Vitamins for Treatment and Prevention of Dementia and Cognitive Decline

Dr Lavretsky discusses her thoughts on the state of geriatric psychiatry from the APA Annual Meeting. She is Professor of Psychiatry at UCLA. She also directs the Late Life Mood, Stress, and Wellness Research Program at the Semel Institute at UCLA. She is an editorial board member of 

Treatment Options in Late-Life Treatment-Resistant Depression

The latest updates in geriatric psychiatry.

Positive Psychiaty, Resilience, and Aging

Depression is a major public health issue and is associated with significant morbidity, mortality, and economic burden. It is the third-greatest contributor to global disease burden

 and affects both low- and high-income countries, with a 12-month prevalence of 5.9% and 5.5%, respectively.

 There is a relative paucity of information on treatment of late-life treatment-resistant depression (TRD). We conducted a survey of the readership of 

 to assess the general attitudes toward the prevalence of-and the existing treatment approaches toward-TRD in adults 60 years and older.

Here we present the results of that survey and discuss the strengths and weaknesses of various approaches to TRD management.

The online survey received 468 responses: 51.6% respondents identified as psychiatrists, 7.7% as psychologists, and 14% as other mental health professionals. The US was well represented, contributing 79.3% of responses: 25.1% came from the Northeast, 16.2% from the Southeast, 17.2% from the Midwest, 8.1% from the Southwest, and 12.7 from the West. The remaining 20.7% of responses came from 41 countries, including Australia, the UK, Canada, and India. Of the respondents, 36.4% had been practicing for more than 25 years. Approximately one-third were in their first decade of practice, and one-third were in their second decade of practice.

 shows the incidence of TRD as reported by survey takers. 

 shows the percentages of patients with TRD, and 

 shows the percentages of TRD patients 60 years and older in the respondents’ practices.

 Please rate how helpful you would find the results of a large randomized study that compares the risks and benefits of augmentation and switching strategies for TRD in patients who are 60+ years old.

Most (71.7%) respondents stated that such a study would be “helpful,” and 61% would find it “extremely helpful.” Importantly, 76.6% of respondents believe their practice would benefit from the findings of such a study.

What treatment choices would you like to see in a randomized study for TRD in patients who are 60+ years old?

The most popular options were augmentation with aripiprazole (53.5%), augmentation with bupropion (49.2%), and augmentation with lithium (45.2%). Switching to bupropion and nortriptyline options were less popular, and each scored 28.4%.

Over one-third of respondents suggested alternative treatment options to be studied. The most common suggestions were psychotherapy; augmentation with antipsychotics; transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS); ECT; the addition of a second antidepressant, both typical (SSRI, SNRI, TCA, MAOI) and atypical (mirtazapine), and newer agents (vortioxetine); as well as methylphenidate and other stimulants, ketamine, and lamotrigine.

Several respondents suggested supplementation with thyroid hormone and, less frequently, folate and omega 3. Other drugs named were memantine, pramipexole, pindolol, nefazodone, buspirone, and glutaminergics. Finally, lifestyle measures such as exercise and various complementary and alternative practices, including acupuncture, were also suggested.

TRD: A significant problem in older adults

This article sheds light on the strengths and weaknesses of various approaches to TRD management in adults 60 years and older.

Author | Helen Lavretsky, MD, MS

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Treatment Options in Late-Life Treatment-Resistant Depression

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