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In our psychiatric practices, we naturally focus on psychopathology and the negative effects that adverse and traumatic experiences have on our patients’ mental health. We assess disaster survivors’ maladjustment in order to develop policies for mental health recovery programs. However, the majority of individuals exposed to disasters or other traumatic events do not develop posttraumatic stress disorder (PTSD) or another lasting psychiatric disorder, although they may experience temporary ripples on the surface of their emotional lives and subclinical symptoms for a time.

In considering the patients seen by my residents and me, I am often in awe of the tremendous strength that many of them have developed despite experiencing horrific abuse, neglect, disasters, extreme poverty, major losses, and other traumatic events. Some who were severely abused or neglected as children become devoted parents or highly functional adults, albeit with effort. How do we understand this 

Resilience is a relatively neglected research topic. A Medline search for medical literature related to “psychological resilience” revealed only 6471 articles, whereas a search for articles related to “PTSD” and “posttraumatic stress” (which does not include other mental health problems associated with trauma) identified 36,682 and 18,823, respectively. In fact, in my own research on biological markers for symptoms and diagnoses of PTSD, depression, and anxiety after disaster, we explored heart rate and blood pressure responses, heart rate vulnerability, and levels of cortisol, interleukin-2, and interleukin-6—yet we did not explore those markers or personal characteristics associated with resilience.

Part of the problem is that resilience is difficult to define. Is it the absence of mental health diagnosis, or is it having temporary symptoms or symptom levels below a defined threshold of distress? Or is it having a fulfilled life and pursuing cherished life goals?

However we define resilience, what factors contribute to it? Are some individuals blessed with a fortunate genetic endowment or temperament? Some research has shown heritability of resilience to range between 33% and 52%. Research on resilience has implicated 

 in expression of neuropeptide Y and regulation of the HPA axis, as well as polymorphisms in noradrenergic and dopaminergic systems and serotonin transporter genes.

 Conversely, epigenetic factors involve methylation, demethylation, and histone changes after stress, especially early life stress, which can change gene expression but not DNA structure, for a variable amount of time, contributing to 

 Does this “hop on, hop off” epigenetic model for stress response inversely explain emotional hardiness? 

 results point to an association between maternal resilience and increased cellular telomere length in newborns, with longer telomeres important in gene transcription, meiosis, and cellular longevity.

 Can promoting maternal adaptation to stress during pregnancy have protective factors in offspring?

Other biological differences associated with positive or negative adjustment after emotional stressors include, but are by no means limited to, hippocampal volume, HPA axis reactivity, the mesolimbic dopamine pathway, and differences in inflammatory markers such as neuropeptide Y, cytokines, and C-reactive protein—before or after trauma exposure.

Experience is also important in resilience. Would stress inoculation in developmental years—having just enough but not too much exposure to hardship—enable individuals to overcome lifetime adversity? This concept has been noted in different cultures—for example, an African proverb intones, “Smooth seas do not make skillful sailors,” and William Shakespeare wrote, “Sweet are the uses of adversity,” in 

. Moreover, as children learn to face inevitable life challenges, having love and support from parent figures or mentors can be protective.

: using active coping mechanisms, cognitive reappraisal of negative thoughts, physical exercise, mindfulness, and meditation.

 Having sufficient social support, higher socioeconomic status, and higher educational levels also protect individuals’ psyches. Thoughtful creators of everything from ancient religious and philosophical texts to modern neurobiological and psychological research have linked resilience and life satisfaction with the wisdom that can come with aging. Thus wisdom, resilience, and better health are promoted by the sharing of life experience lessons from older to 

Drawing on the tenets of psychoanalysis, some experts have recommended the use of mature ego defenses, such as creativity, humor, and altruism, in the face of difficulty. Humor and altruism have the particular benefit of drawing others in, thus increasing social support.

Relevant to our current pandemic, the results of a recent large study of frontline health care workers caring for hospitalized COVID-19 patients linked psychological resilience with positive emotions, self-efficacy, sense of purpose in life, and social support (including leadership support), as well as with avoidance of maladaptive behaviors, such as substance abuse.

In sum, resilience is a rich but understudied field for psychiatric research. In this Special Report, we are honored to present several expert colleagues’ wisdom on psychiatric resilience in diverse areas.

is vice chair of education for psychiatry and behavioral sciences, holds the Professor and Arnold and Bess Ungerman Endowed Chair in Psychiatry and the Robert Glenn Rapp Foundation Presidential Professorship of Medicine, and serves in the Adult Mental Health Services at The University of Oklahoma College of Medicine, Oklahoma City.

. Guilford Psychiatry Series. Guilford Press; 1987.

2. Wu G, Feder A, Cohen H, et al. Understanding resilience. 

3. Dudley KJ, Li X, Kobor MS, et al. Epigenetic mechanisms mediating vulnerability and resilience to psychiatric disorders. 

4. Verner G, Epel E, Lahti-Pulkkinen M, et al. Maternal psychological resilience during pregnancy and newborn telomere length: a prospective study. 

5. Southwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. 

6. Jeste DV, Lee EE. The emerging empirical science of wisdom: definition, measurement, neurobiology, longevity, and interventions. 

7. Elisei S, Sciarma T, Verdolini N, Anastasi S. Resilience and depressive disorders. 

8. Pietrzak RH, Feingold JH, Feder A, et al. Psychological resilience in frontline health care workers during the acute phase of the COVID-19 pandemic in New York City. 

Resilience is a relatively neglected topic of research, but it has the power to dramatically improve patients' lives. 

What Is Resilience?

Despite the difficult past 2 years, negative views of mental health persist. Shahla Modir, MD, discusses the results of the 

 and gives reccomendations to improve mental well-being. 

 is the Chief Medical Officer at All Points North Lodge and the Chief Psychiatrist at Avalon Malibu, Summit Malibu. 

A recent All Points North Lodge survey found 37% of Americans are comfortable discussing mental health, but 44.7% have never tried counseling. What is preventing them from seeking care? 

Paving a Path Forward to Overcome Stigma

“Come now, and let us reason together.”

"Reason is, and ought only to be, the slave of the passion."

A few weeks ago, having been fully vaccinated against COVID-19, I ventured out for a long-postponed haircut without wearing a mask, knowing that the pleasant but tempestuous woman who regularly cuts my hair had received the single-shot Johnson & Johnson vaccine. But when I told her I had received 2 doses of the Pfizer vaccine, she looked horrified. “Oh, no!” she said, “That vaccine is going to rewrite your DNA and leave your immune system damaged for life!” I decided this was not the time to challenge her or to explain that, no, the m-RNA vaccines do not rewrite one’s genetic code or destroy the immune system—especially with her scissors 3 inches from my face.

Then, a few days ago, I read about the increasing use of so-called 

 in California, which is experiencing extreme drought conditions. According to the 

, these “water dowsers” claim that they can “…locate streams of water in the fractures in the earth’s bedrock, using 2 L-shaped rods that together resemble an old-fashioned television antenna.”

 These individuals are now heavily booked and well-paid for their services, despite the fact that hydrogeologists describe water dowsing as “

The common thread in these personal vignettes is, of course, a deep-seated denial of science and a mistrust of scientific 

—a word that is nowadays pronounced with a kind of dismissive hiss. Indeed, experts in epidemiology and infectious disease, such as Anthony Fauci, MD, are not merely doubted by a substantial proportion of the public—they are threatened with bodily harm for advocating vaccination against COVID-19.

It is easy to explain away such science denial as the result of mistaken information and biased reasoning, exacerbated by 

grossly misleading claims on social media

 To be sure, these factors do contribute to science denial and the derogation of scientific authority. As physicians, we have an obligation to provide our patients with accurate information that might 

counteract such irrational and unfounded beliefs

But as psychiatrists, we know that reason has its limitations, absent a deep understanding of the feelings—indeed, the 

—that shape human belief and behavior. The great Scottish philosopher, David Hume (1711-1776) understood this well, arguing, in his 

reason is, and ought only to be, the slave of the passions.”

 According to philosopher AT Nuyen, Hume was not negating the importance of reason in shaping human belief and behavior, but merely putting it in proper perspective—arguing, in effect, that “…reason alone does not move one to act. The force that propels one to action is the passion, whether it be love, or anger, or pride, or envy, or fear, or desire.”

Hume’s great insight has been amply confirmed by modern-day psychological research, notably that of 

, a professor of neurology and neurosurgery at Stanford University.

 Sapolsky’s studies of cognitive function have convinced him that, “You can’t reason somebody out of something they weren’t reasoned into in the first place,” and that “…We’re certainly set up to only have resonating in our head the stuff we want to hear.” He adds that, “…people who are least curious, most unwilling to explore novelty, [and] most reflexively hostile about it are people who are anxious.”

And who better to empathize with and explore anxiety than psychiatrists? Indeed, Sapolsky urges us to emulate the teenager, whose “…deeply felt sense of empathy” is often lacking in adults. Had I been doing therapy with someone like the woman who cuts my hair, I would have homed in on the anxiety that probably underlay her unfounded beliefs about COVID vaccines. If I were working therapeutically with the rancher or vineyard owner shelling out good money to a “water witch,” I might focus on the understandable feelings of despair and desperation driving that behavior. Yes, I would also gently guide these individuals to sources of accurate information—but only after connecting with them on an 

 (1623-1662) wisely put it, “The heart has its reasons which reason knows nothing of... We know the truth not only by the reason, but by the heart.”

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of

(2007-2010). He is the author, most recently, of

1. Nuyen AT. David Hume on reason, passions and morals. 

2. Albeck-Ripka L. Two rods and a ‘sixth sense’: in drought, water witches are swamped. 

. July 17, 2021. Accessed July 21, 2021. 

https://www.nytimes.com/2021/07/17/us/california-drought-water-witches.html

3. Mello MM, Greene JA, Sharfstein JM. Attacks on public health officials during COVID-19. 

4. Ortutay B, Seitz A. Defying rules, anti-vaccine accounts thrive on social media. 

. March 12, 2021. Accessed July 21, 2021. 

https://apnews.com/article/anti-vaccine-accounts-thrive-social-media-e796aaf1ce32d02e215d3b2021a33599

5. Pies RW, Pierre JM. Believing in conspiracy theories is not delusional. 

. February 4, 2021. Accessed July 21, 2021. 

https://www.medscape.com/viewarticle/945290#vp_1

6. Robert Sapolsky on how to become ‘less twitchy,’ embrace empathy. FRED Leadership. Accessed July 21, 2021. 

https://static1.squarespace.com/static/5de939086957252759882614/t/5e332ad18d20f734ba38a27c/1580411601821/Robert-Sapolsky-story-for-FRED.pdf

https://wiselifelesson.com/quotes/the-heart-has-its-reasons-which-reason-knows-nothing-of-we-know-the-truth-not-only-by-the-reason-but-by-the-heart-blaise-pascal/

Brumfiel G. Anti-vaccine activists use a federal database to spread fear about COVID vaccines. June 14, 2021. Accessed July 21, 2021. 

https://www.npr.org/sections/health-shots/2021/06/14/1004757554/anti-vaccine-activists-use-a-federal-database-to-spread-fear-about-covid-vaccine

How can you reason with someone who is determined to believe misinformation? One doctor shares his reflections.

Anti-Vaxxers and Water Witches: Mistrust of Science and the Limits of Reason

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.

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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https://www.who.int/news-room/fact-sheets/detail/depression

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

Coronavirus

What Is Resilience?

Paving a Path Forward to Overcome Stigma

Anti-Vaxxers and Water Witches: Mistrust of Science and the Limits of Reason

Addressing the Cognition Crisis in Our COVID-19 World

Going Alone: How COVID-19 and Racism Are Exposing Gaps in AAPI Mental Health Care

Let’s Use the Pandemic to Change Mental Health Care for the Better

Greet the Sun: 3 Tips to Feel Normal Again

COVID-19 Blues

Walking on Sunshine

Developing a Collaborative Approach to Post-Acute Sequelae of SARS-CoV-2 Infection