FALL 2019 SYNERGIES DEPARTMENT OF PSYCHIATRYDEPARTMENT

Anxiety in Late-Life

CME Credit Akiko Mizuno, PhD Disclosures: Drs. Mizuno and Andreescu report Postdoctoral Associate, Geriatric Psychiatry Neuroimaging Laboratory receiving grant support from the National Institute Department of Psychiatry of Mental Health. University of Pittsburgh School of Medicine Instructions: To take the CME evaluation and UPMC Western Psychiatric Hospital receive credit, please visit UPMCPhysician Resources.com/Psychiatry, and click on UPMC Synergies: Fall 2019. Carmen Andreescu, MD Accreditation Statement: In support of improving Associate Professor of Psychiatry patient care, the University of Pittsburgh is jointly Co-Director, Geriatric Psychiatry Neuroimaging Laboratory accredited by the Accreditation Council for Department of Psychiatry Continuing Medical Education (ACCME), the University of Pittsburgh School of Medicine Accreditation Council for Pharmacy Education UPMC Western Psychiatric Hospital (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

The University of Pittsburgh designates enduring Introduction material activity for a maximum of 0.5 AMA PRA Worry is a universal part of human experience. Although worry may have some evolutionary advantages Category 1 Credit™. Physicians should claim only by detecting threat and planning strategies to avoid harm, excessive worry perturbs everyday activities the credit commensurate with the extent of their participation in the activity. and reduces quality-of-life. Generalized anxiety disorder, characterized by excessive and persistent worry, is one of the most prevalent anxiety disorders in the United States and worldwide. Our team investigates Other health care professionals will receive a certificate of attendance confirming the number anxiety disorders, particularly among older adults, because of its high prevalence and its pronounced of contact hours commensurate with the extent impact on health conditions. For example, anxiety has been tied to increased cardiovascular burden and of participation in this activity. worsening cognitive decline. Despite severe health implications, late-life anxiety is underdiagnosed and undertreated in clinical practice, and the neural mechanisms underlying anxiety are understudied.

Background Severe worry is defined as intense and uncontrollable worry associated with an interruption in functioning and reduced quality-of-life. In the United States, it is estimated that 31.1% of adults suffer from severe worry (with or without a diagnosis of anxiety disorder) at some point in their life, and anxiety disorders have a higher prevalence in females than males.1 With the exception of specific phobias, generalized anxiety disorder (GAD) is the most common form of anxiety disorder. GAD is characterized by severe worry about everyday activities and life events. Interestingly, the prevalence of many anxiety disorders appears to decrease in late-life, although GAD maintains similar prevalence rates in young and old.2-4 Compared to other anxiety disorders, GAD has a relatively late-onset, and almost half of older patients with GAD report the onset of their disorder after age 50.5 In community samples, UPMC Western Psychiatric Hospital one study suggests that 20% of older adults report severe worry.6 The prevalence of anxiety disorders in is a part of UPMC Presbyterian Shadyside, which is consistently late-life, however, is believed to be underestimated due to the challenges of assessing and diagnosing named to the U.S. News & World anxiety in the elderly, which we will discuss in detail later in this paper. Report Honor Roll of America’s Best Hospitals. (Continued on Page 2)

Affiliated with the University of Pittsburgh School of Medicine, UPMC Presbyterian Shadyside is ranked among America’s Best Hospitals by U.S. News & World Report.

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Late-life anxiety is anxiety Late-life 46 while others report a positive a positive report while others 24

In a prospective longitudinal study, longitudinal study, In a prospective 43 39 28 48-51 Furthermore, anxiety may represent an early represent may anxiety Furthermore,

52 42-45 Stress-induced neurotoxic injury may result in result injury may neurotoxic Stress-induced 38-41 The wide range of reports may result from diagnostic diagnostic from result may of reports wide range The Another study reported that anxiety symptoms predicted predicted symptoms anxiety that reported Another study 25,26 53 Additionally, AD participants may have difficulty relaying relaying difficulty have may AD participants Additionally, 27 Anxiety-induced chronic stress may increase cerebrovascular cerebrovascular increase may stress chronic Anxiety-induced 35-37 Late-life is often accompanied by health challenges, and anxiety health challenges, and anxiety by accompanied is often Late-life 47 depression. coronary following in patients years five at events major cardiovascular surgery. bypass artery Use Disorders and Substance Anxiety Late-Life is with anxiety is highly comorbid that of disorder Another type Comorbidity the National to According (SUD). use disorder substance individuals with SUD also meets in 2005, one in five Replication Survey SUD in older adults is an emerging disorder. an anxiety for the criteria precipitate late-life anxiety. For example, a higher amyloid burden, the burden, a higher amyloid example, For anxiety. late-life precipitate in a role of playing is suspected of AD, biomarker established most reported have studies recent groundbreaking Several anxiety. late-life in particular, burden; and amyloid anxiety/worry between an association burden beta-amyloid between the association moderate may anxiety decline. and cognitive AD. preclinical of manifestation and Medical Comorbidity Anxiety Late-Life increased have disorders anxiety individuals with age groups, Across causes. and unnatural natural both from mortality quality-of- health-related and poorer disability with greater associated life. such as gastrointestinal medical conditions, with several is associated disease, cardiovascular diabetes, hyperthyroidism, or hypo- problems, disorders. and respiratory disease has and cardiovascular anxiety the link between recently, More as has been reported anxiety Thus, studies. of several been the focus surgery. bypass coronary after for mortality factor risk a significant with a associated was anxiety that reported meta-analysis A recent risk 1.41], [relative mortality risk of cardiovascular elevated significantly and risk 1.71], [relative stroke risk 1.41], heart disease [relative coronary risk 1.35]. [relative heart failure risk with increased associated were levels symptom higher anxiety including of other risk factors, independent stroke incident for The association between dementia and anxiety symptoms is still a still is symptoms anxiety and dementia between association The difference no significant reporting with some studies of debate, matter dementia in the elderly with symptoms of anxiety in the prevalence subjects, nondemented to compared association. methodological well as as with dementia, patients in difficulties in both seen are that symptoms The studies. the between differences and poor fatigue, such as restlessness, and dementia, disorders anxiety of context in the anxiety to distinguish it difficult make concentration, dementia. on rely to researchers prompting about themselves, information symptoms internal assess to ability with limited reports caregiver and rumination. such as worry be decline may cognitive and anxiety between causal relationship The decline cognitive to contribute may anxiety Chronic bidirectional. load. allostatic increase that pathways stress-related various through and anxiety trigger increased may cognition worsening Conversely, worry. and unopposed glutaminergic inflammation, chronic burden, the hippocampus and (e.g., regions brain in vulnerable excitotoxicity cortex). prefrontal On the other hand, more decline. and cognitive neurodegeneration may cognition declining support that to available is becoming evidence

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20 10 and 28% of depressed and 28% of depressed 9 Large longitudinal studies of longitudinal studies Large 9 Anxiety symptoms often persist after after persist often symptoms Anxiety lower social functioning, and higher severity and higher severity social functioning, lower 11 15,16 Likewise, the presence of anxiety symptoms symptoms of anxiety the presence Likewise, 10,13,14 and 26.1% met criteria for any depressive depressive any for criteria met and 26.1% 12 7,8 7,8 Older adults with depression and concurrent anxiety anxiety and concurrent Older adults with depression 15 Likewise, 48% of patients with a major depressive disorder disorder with a major depressive 48% of patients Likewise, For example, individuals with late-life GAD show deficits in GAD show individuals with late-life example, For 9 19 multiple cognitive domains, including language, processing speed, processing domains, including language, multiple cognitive function. and executive memory, and delayed immediate impairment and Alzheimer’s disease (AD), and older adults with a and Alzheimer’simpairment disease (AD), risk of cognitive an increased have of anxiety level clinically relevant decline. Late-Life Anxiety and Risk of Dementia Anxiety Late-Life with declining cognitive comorbid is frequently anxiety Late-life of cognitive factor predictive age is the strongest In general, functions. symptoms in the elderly may increase the risk of cognitive decline. the risk of cognitive increase in the elderly may symptoms sectional studies and observational research have shown that anxiety anxiety that shown have research and observational studies sectional older adults with both anxiety and depressive disorders are more likely likely more are disorders and depressive older adults with both anxiety treatment. discontinue to relapse. depressive the risk for and increase of depression remission to treatment. to the antidepressants, to respond time to 50% more required symptoms Also, disorders. anxiety for late-life treatment pharmacological first-line suicidal risk, greater somatic symptoms, and an increased risk of and an increased symptoms, somatic suicidal risk, greater impairment. cognitive response affects negatively and anxiety of depression Comorbidity greater risk for chronicity, risk for greater symptoms. of anxiety with greater associated older adults has been among depressed Late-life anxiety is associated with unfavorable outcomes in health outcomes with unfavorable is associated anxiety Late-life and of anxiety and comorbidity functions, cognitive and age-related including outcomes, negative further increases disorders depressive disorder. diagnosis, disorder anxiety also had a current GAD. for criteria diagnostic meet would elderly patients restlessness, sleep changes, and fatigue. Among older adults with sleep changes, and fatigue. restlessness, major for criteria 23% of them also met 13 to disorders, anxiety disorder depressive transdiagnostic quality of worry, a symptom present in both anxiety in both anxiety present a symptom worry, of quality transdiagnostic share of disorders In addition, both classes disorders. and depressive concentration, decreased including irritability, other symptoms, Late-Life Anxiety and Depression Anxiety Late-Life has been reported disorders and depressive of anxiety Comorbidity of the is partially a result comorbidity This all age groups. for Relevant Comorbidities Relevant Late-onset GAD also is distinguished from early-onset GAD by a more a more GAD by early-onset from GAD also is distinguished Late-onset hypertension), (e.g., with medical comorbidities association frequent after quality-of-life health-related and poorer disability, greater symptoms. and depressive medical burden for controlling Late-onset anxiety disorder risk factors in older adults are often often are in older adults risk factors disorder anxiety Late-onset such as bereavement, events/stressors and include life age-related and social isolation. status, caregiver disability, and illness chronic late-life anxiety also reported the high risk of relapse, with recurrence recurrence with the high risk of relapse, also reported anxiety late-life six years. to three after 52% to 39 up to rates and chronicity State of Health report in the United States, anxiety disorders were disorders anxiety States, United in the report of Health State number of years-lived-with- with the largest diseases one of the four musculoskeletal back pain, other low following in 2010 disability disorder. depressive and major disorders, The high prevalence of late-life anxiety is emerging as a significant as a significant is emerging anxiety late-life of prevalence high The the 2013 to According aging population. in an burden public health

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SNRIs One small 89 93 79-81 ) is a popular ® Other classes of Other classes 90 Although SSRIs and Although SSRIs 103-105 82.83 and hyponatremia. and the risk for misuse. for and the risk 88 60,61 A recent study found that buspirone buspirone that found study A recent 100 Mirtazapine (Remeron bone loss, 98

87 as well as the increased risk of sudden death risk of sudden death as the increased as well 99 Quetiapine has demonstrated efficacy and efficacy has demonstrated Quetiapine 91 The study reported multiple side effects such as such multiple side effects reported study The 95-97 93 101 while others have failed to prove the superiority of CBT of CBT the superiority prove to failed have while others 101,102 late-life anxiety remains problematic because of well-known risks of well-known because problematic remains anxiety late-life impairment, cognitive such as falls, inhibitors reuptake serotonin such as selective Antidepressants, (SNRIs), inhibitors reuptake and serotonin-norepinephrine (SSRIs) disorders. anxiety late-life for treatment the first-line considered are GAD) (predominantly anxiety SSRIs in late-life of effectiveness The trials. controlled randomized in three has been reported equally be to found also been have XR and duloxetine) (venlafaxine younger adults. and efficacious in older to specific are risks that several well-tolerated, relatively SNRIs are risk of falls, including an elevated be monitored, need to late-life demonstrated in numerous studies for various psychological disorders. disorders. psychological various for studies in numerous demonstrated has been studied that psychotherapy of is a type Although CBT Some trials mixed. remain the results anxiety, in late-life extensively late-life CBT in of efficacy moderate shown have and meta-analyses anxiety, lists. or waiting therapy supportive over cognition and of maladaptive modification targets CBT Since cognitive learn new to the ability investigated one study behaviors, patients that reported study The skills among older adults with anxiety. 10 mg of escitalopram. SSRIs. to and as an adjunctive both as a monotherapy tolerability mg/day) (50-300 XR monotherapy quetiapine (N=450), study a large in the elderly (number anxiety late-life treating efficacious in was = 8). treat needed to nausea. and headache, dry mouth, dizziness, drowsiness, strategy. as an augmentation its efficacy showed of risperidone study benefits of the potential balance clinicians need to Importantly, in the elderly with substantial antipsychotics second-generation and hyperglycemia, gain, weight including side effects, metabolic cholesterol, increased events. and cardiovascular because of its mainly in late-life of anxiety the treatment for choice is for its efficacy evidence but the on sleep and appetite, effects and inconsistent. limited strategies. pharmacological on second-line focused have studies Few although it is anxiety, late-life efficacious in found was Pregabalin pregabalin pregabalin (i.e., of the clinical impact assess to difficult on the Hamilton reduction greater with a two-point associated was Scale than placebo). Anxiety of for the treatment as sertraline well-tolerated and as effective was anxiety. late-life Psychotherapy has been (CBT) therapy cognitive-behavioral of efficacy The gastrointestinal bleeding, gastrointestinal for is particularly recommended blood pressure monitoring venlafaxine). (especially higher doses of SNRIs and (TCA) antidepressants drugs, such as tricyclic antidepressant be efficacious. may (MAOI) inhibitors monoamine oxidase irreversible other to cases resistant only for should be considered they However, concerns. and safety profiles their side-effect options due to treatment of late-life drugs in the treatment use of antipsychotic Off-label with only antipsychotic The in the community. is common anxiety with doses is quetiapine, disorder anxiety in of efficacy some evidence or mg being as efficacious as 20 mg of paroxetine 50-150 between

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71-73 62,63 However, 69 In another Some studies Some studies 67 They also are also are They 74-76 65 Among prescription drug drug Among prescription These physiologic These 68 70 54,55 Older patients are more likely to to likely more are Older patients 55,56 The treatment of late-life anxiety disorders disorders anxiety of late-life treatment The 30 However, treatment of late-life anxiety disorders is disorders anxiety of late-life treatment However, However, research is scarce in this area. There have have There area. in this is scarce research However, 65 53 However, the mass-scale use of benzodiazepines in use of benzodiazepines the mass-scale However, The preference of treatment types appears to be to appears types of treatment preference The More recently, interest in the medicinal use of cannabis in the medicinal interest recently, More 77,78 66 57-60 have found benzodiazepines efficacious in reducing anxiety symptoms symptoms anxiety reducing efficacious in benzodiazepines found have in older adults. treatment for anxiety in late-life is benzodiazepines. in late-life anxiety for treatment As seen in other age groups, the most common pharmacological pharmacological common the most As seen in other age groups, difficulties), antiadrenergic (orthostatic hypotension), and hypotension), (orthostatic antiadrenergic difficulties), effects. confusion) dizziness, (drowsiness, antihistaminergic changes increase the risk of medication-related side effects, such as side effects, the risk of medication-related changes increase delirium, cognitive constipation, (urinary retention, anticholinergic and decreased activity of target receptors. of target activity and decreased several pharmacokinetics and dynamics changes related to reduced reduced to and dynamics changes related pharmacokinetics several output, cardiac lower metabolization, and hepatic glomerular filtration that may not be necessary for other age groups. Elderly patients have have Elderly patients other age groups. for not be necessary may that is more effective than psychotherapy for late-life anxiety. for late-life than psychotherapy effective is more assessment a comprehensive older adults requires for pharmacotherapy A meta-analysis of 32 studies concluded that pharmacotherapy that concluded studies of 32 A meta-analysis Pharmacotherapy study with a community survey, the majority of older adults reported of older adults reported the majority survey, with a community study treatment. as the preferred psychotherapy classes but are more reluctant to join group therapies. join group to reluctant more but are classes different between older and younger adults. One study reported that that reported study One younger adults. older and between different in psychoeducational participate be willing to to older adults tend more likely to drop out of treatment due to perceived stigma related to to related stigma perceived due to out of treatment drop to likely more health. mental likely to seek help from mental health professionals. mental from seek help to likely uncommon remission. uncommon less older adults are For instance, specific challenges. several raises disorders are more likely to be chronic, with frequent relapses and relapses with frequent be chronic, to likely more are disorders untreated anxiety. untreated anxiety adults. Late-life than in younger successful less generally Adequate treatment of late-life anxiety disorders is particularly is particularly disorders anxiety of late-life treatment Adequate with risks associated and mortality the morbidity given important Treatment or withdrawal), and common factors theory (shared personality/ theory (shared factors and common or withdrawal), and SUD). anxiety between vulnerabilities neurobiological anxiety), substance-induced anxiety (anxiety caused by intoxication caused by (anxiety anxiety substance-induced anxiety), the relationship between anxiety and SUD are unclear, there are several several are there unclear, and SUD are anxiety between the relationship self-treat used to (substances hypothesis self-medication hypotheses: The comorbidity between anxiety and SUD complicates treatment and treatment SUD complicates and anxiety between comorbidity The the mechanisms underlying Although of SUD. the prognosis worsens should not be underestimated. should not be underestimated. adults, and the potential of side effects and drug-drug interactions and drug-drug interactions of side effects adults, and the potential symptoms such as chronic pain, insomnia, and mood symptoms. pain, insomnia, such as chronic symptoms in older of its efficacy evidence little is very there so far, However, relevant for older individuals due to the increased frequency of frequency the increased due to older individuals for relevant impairment. is particularly use of cannabis/cannabinoids The has been increased. receive opioid and benzodiazepine prescriptions, and they are more more are they and prescriptions, and benzodiazepine opioid receive cognitive and falls risk of such as increased side effects have to likely to high rates of fatal overdosing. fatal of high rates to abuse in older adults in the United States. adults in the United abuse in older due concern misuse is a particular opioid and benzodiazepine misuse, around the world. around drug prescription illicit and for admissions in treatment been increases public health concern that is associated with aging in populations in populations with aging associated is that health concern public

efficacy. However, longitudinal observations indicate that up to half up that indicate longitudinal observations However, efficacy. populations. in geriatric six years to in three relapse of patients interventions and psychotherapeutic used pharmacological Commonly worry reducing for particularly ineffective are anxiety in late-life modulate aims to study TMS treatment Our fMRI-directed severity. worry. with severe associated are that in the regions plasticity cortical induce to 1 Hz) TMS at TMS (low-frequency uses inhibitory project This Details severity. worry reduce and, consequently, modulation neural www.gpn.pitt.edu. at can be found these projects regarding not know the mechanistic pathways connecting anxiety/worry with anxiety/worry connecting pathways the mechanistic not know and a model in which chronic examining are We decline. cognitive increased decline through the risk of cognitive augment worry severe via beta-amyloid measure we In this study, markers. stress chronic (PiB-PET) Tomography Emission B Positron Compound Pittsburgh of chronic types as three as well AD neuropathology, of as a measure stressor- and cortisol level, cytokines, (proinflammatory markers stress been has factor No modifiable risk reactivity). blood pressure evoked is such a factor and identifying of AD, the course change to established severe that proposes Our study goal of much AD research. a common change the trajectory can possibly that factor risk is a modifiable worry the reduce and, consequently, decline or AD progression of cognitive with AD. associated burden enormous socioeconomic may worry severe of how additional pathways two testing are also We hippocampal are pathways two risks. These AD and AD-related affect is one of the earliest Hippocampal atrophy burden. and vascular atrophy but the mechanisms of degeneration of AD, markers validated and most stress- that hypothesize We unknown. still in the hippocampus are worry with severe associated excitotoxicity glutamate induced this study As another pathway, hippocampal atrophy. to contributes and disease vascular (both peripheral burden cerebrovascular measures worry severe that suggest studies Several disease.) small vessel cerebral an posit that We disease and stroke. cardiovascular for is a risk factor AD. the risk for disease increases risk of cardiovascular increased moderate have anxiety late-life for treatments available Currently, than psychotherapy in late-life anxiety, many elderly anxious subjects subjects anxious elderly many anxiety, in late-life than psychotherapy appear interventions These interventions. psychotherapeutic prefer and cultural the needs, expectations, to when tailored best work to individuals. anxious of older backgrounds lab is currently (GPN) Neuroimaging Psychiatry Geriatric The of late- mechanisms neural the exploring studies several conducting with transcranial interventions as experimental as well anxiety, life of these One late-life. in worry severe for (TMS) stimulation magnetic and anxiety mechanisms of late-life neural identify aims to studies changes of aging (e.g., with the neuropathologic its relationship focus we In particular, disease). matter and white neurodegeneration in manifests that symptom as a transdiagnostic worry on severe to uses neuroimaging study This disorders. and anxiety mood several during worry and during “rest” connectivity the functional measure further investigate We reappraisal). (i.e., and regulation induction burden) hyperintensity matter white by age (measured brain how and functional severity worry between the relationship moderates develop us to will allow project This network. of the brain connectivity are that networks neural aberrant targeting interventions effective worry. to older individuals with severe specific and cognitive anxiety late-life between Although the association do still we studies, recent in several has been reported impairment

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115 One study has One study

Overall, Overall, 112 107-109 Older adults were Older adults were 111 Telephone-delivered Telephone-delivered 113 110 These results indicate results These 106 To accommodate late-life specific late-life accommodate To These promising results suggest results promising These 104 118 Also, more group-specific adjustments group-specific more Also, MBSR for anxious elderly patients with elderly patients anxious MBSR for 110 116 Another study reported that patients with late-life with late-life patients that reported Another study 105 Furthermore, another study reported that CBT remained remained CBT that reported another study Furthermore, 102 102 and monitoring of the side-effects. Although SSRIs are more effective effective more SSRIs are Although of the side-effects. and monitoring Antidepressants remain the first-line treatment for late-life anxiety; anxiety; for late-life treatment the first-line remain Antidepressants common be the most to continue benzodiazepines however, the same for options are treatment The treatment. pharmacological consideration need extra to tend but older patients age group, every is to identify anxiety symptoms based on self-reporting that may that based on self-reporting symptoms anxiety identify is to function. cognitive impaired by be hampered cognitive decline and cardiovascular disease. Aging populations and populations Aging disease. decline and cardiovascular cognitive disease and Alzheimer’s of cardiovascular prevalence the increased for of these links. In clinical practice the significance disease heighten disorder anxiety to late-life specific a challenge disorders, anxiety impairment and distress. While it has long been known that late-life late-life that it has long been known While and distress. impairment recent use disorders, mood and substance with is comorbid anxiety with both anxiety late-life support further links between studies University of Pittsburgh functional causes significant and is highly prevalent anxiety Late-life the need for further investigation and validation on larger samples. larger on and validation further investigation the need for Conclusion and Current Research at the cognitive dysfunction also has shown promising preliminary results. preliminary promising also has shown dysfunction cognitive in improvement also has shown therapy and Commitment Acceptance in elderly patients. severity worry considers the specific symptoms of the patients and allows flexibility and allows of the patients symptoms the specific considers needs. individual patient to components tailor the treatment to anxiety reduce to (MBSR) is proven reduction stress Mindfulness-based in older adults. symptoms Different innovative psychotherapeutic approaches are actively being actively are approaches psychotherapeutic innovative Different that protocol uses a personalized modular CBT example, For examined. therapy; however, it might be clinically relevant to question whether question to be clinically relevant it might however, therapy; Augmenting effective. be more would and medication CBT combining and reduced symptoms worry improved with CBT treatment SSRI anxiety. adults with late-life in older rates relapse more likely to complete Internet-delivered CBT than younger adults, than younger CBT Internet-delivered complete to likely more response. robust adults had a more although younger ­ than pharmaco effective be more to is not proven psychotherapy American subjects were proven to be effective. to proven were American subjects telephone-delivered superior to was populations rural for CBT anxiety. in late-life therapy supportive nondirective a more simplified approach. a more of psychotherapeutic the impact facilitate to can be implemented older African for spirituality and/or religion Incorporating interventions. CBT for older patients with anxiety. with older patients for CBT such as outcomes, better provide can needs, some modifications of concepts, review phone calls, a weekly reminder between-session and components, instruction easy with relatively in-home assignments Late-life specific challenges in CBT may be accounted for by diminishing for accounted be may in CBT specific challenges Late-life reappraisal. particularly the cognitive ability, cognitive efficacious kind be the most of may therapy relaxation that reported pharmacotherapy prior to receiving CBT. receiving prior to pharmacotherapy benefits. in older adults brings long-term CBT that anxiety who received CBT maintained gains up to one year after CBT CBT after one year gains up to maintained CBT received who anxiety treatment. following than immediately follow-up at one-year beneficial more of months three least at received who in patients treatment with late-life anxiety were able to acquire new cognitive skills and use skills and use cognitive new acquire able to were anxiety with late-life them effectively.

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UPMC WESTERN PSYCHIATRIC HOSPITAL ADDRESS CORRESPONDENCE TO: UPMC Western Psychiatric Hospital 3811 O‘Hara St. Pittsburgh, PA 15213 Integrating Clinical and Technological Innovation, 1-877-624-4100 Research, and Education David A. Lewis, MD Medical Director and Director of Research, Psychiatric care at UPMC Presbyterian Shadyside has been the province of UPMC Western Psychiatric Hospital UPMC Western Psychiatric Hospital, since it first opened its doors in 1942. Distinguished Professor of Psychiatry UPMC and its academic partner, the Department of Psychiatry of the University and Neuroscience, and Thomas Detre Chair of Academic Psychiatry of Pittsburgh School of Medicine, constitute one of the leading centers for research and treatment of individuals who have challenging or particularly Chairman, Department of Psychiatry, University of Pittsburgh School difficult mental health conditions and addictive disorders. of Medicine For more than 60 years, the integration of research, academia, and clinical services has infused best-practice research into clinical settings for the individuals who need it most. A $20 billion health care provider and insurer, Pittsburgh-based UPMC is inventing new models of We serve individuals across the lifespan, from young children to aging adults. patient-centered, cost-effective, accountable care. The largest nongovernmental employer in Pennsylvania, Through our inpatient and outpatient continuum of care, we provide services UPMC integrates 89,000 employees, 40 hospitals, 700 doctors’ offices and outpatient sites, and a nearly for more than 400,000 patient contacts each year. 3.6 million-member Insurance Services Division, the largest medical insurer in western Pennsylvania. In the The Department of Psychiatry is a leading recipient of research funding from most recent fiscal year, UPMC contributed $1.2 billion in benefits to its communities, including more care to the the National Institutes of Health (NIH), including research grants from multiple region’s most vulnerable citizens than any other health care institution, and paid $587 million in federal, state, NIH institutes such as the National Institute of Mental Health, the National and local taxes. Working in close collaboration with the University of Pittsburgh Schools of the Health Institute on Aging, and the National Institute on Drug Abuse. Sciences, UPMC shares its clinical, managerial, and technological skills worldwide through its innovation and commercialization arm, UPMC Enterprises, and through UPMC International. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside on its annual Honor Roll of America’s Best Hospitals and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals. For more To learn more about the UPMC Department information, go to UPMC.com. of Psychiatry, please visit UPMCPhysicianResources.com/Psychiatry. USNW513103 AS/MP 11/19 © 2019 UPMC