CGPR: Please tell us about the work you do and the patients you see.

Dr. Lavretsky: I’m a geriatric psychiatrist and the director of research for the integrative medicine collaborative at UCLA. I also direct a long-COVID clinic where I use integrative medicine. Whatever I learn from geriatric psychiatry and integrative medicine, I apply to treating patients with long-COVID.

CGPR: You use the term “integrative medicine.” Is this different from complementary and alternative medicine?

Dr. Lavretsky: Alternative is no longer a term we use because the use of these therapies is widely accepted. Alternative medicine refers to modalities that are not part of mainstream medicine, which may have less of an evidence base. Integrative medicine offers a new model that refers to whole-person care. We use complementary modalities along with mainstream modalities to achieve the same therapeutic goal.

CGPR: So, the correct term is “complementary and integrative medicine” (CIM)?

Dr. Lavretsky: Currently, yes. You may also hear about “holistic medicine” or “Whole Health,” which is the philosophy of the National Center for Complementary and Integrative Health and the Veterans Administration healthcare system (Editor’s note: For more on Whole Health, please see Q&A with Dr. Phillips on page 8). CIM is well-being driven, not disease driven. The patient participates in creating their own well-being as a part of a dyadic decision with their clinician. This is largely absent from the Western medicine model, which often takes a patient’s participation out of consideration and is more prescriptive. CIM is also more holistic, in contrast to Western medicine, which is often focused on a single organ.

CGPR: Can you share an example of how you use CIM?

Dr. Lavretsky: I treated a 68-year-old woman who was experiencing several life stressors, including contemplating retirement. She presented with anxiety, depression, insomnia, and memory complaints. After I explained the neuroplastic and stress-reducing properties of several mind-body interventions, she selected brief breathing practices and grounding exercises, as well as connecting with nature. She practiced on the weekends and at work when experiencing anxiety. To help her insomnia, she chose to start melatonin, drink valerian root tea, use lavender aromatherapy, and listen to calm music at night. After two weeks, she reported a greater sense of calm and an improved ability to regulate her negative emotions. She also experienced less fear of failing at her job.

CGPR: What are the advantages of CIM in treating mental illnesses in older adults?

Dr. Lavretsky: CIM reduces the need for polypharmacy, resulting in fewer drug interactions and side effects. Lifestyle practices, like stress reduction techniques such as meditation or yoga, can serve as lifelong tools to help patients lead healthier lives. Rather than treat acute diseases, integrative medicine helps prevent chronic diseases—including depression and anxiety—in at-risk populations, like stressed dementia caregivers (Nguyen SA et al, Curr Psychiatry Rep 2022;24(9):469–480).

CGPR: What are the disadvantages of CIM?

Dr. Lavretsky: Patient involvement is crucial, but not everybody tries to participate. Some patients are skeptical given the limitations in research and regulation. And although CIM can reduce polypharmacy, supplements can be part of the treatment plan, which then may have drug interactions and side effects. Additionally, many modalities are not covered by insurance.

CGPR: For patients who are new to the idea of mind-body practices, how do you structure your introduction?

Dr. Lavretsky: I ask patients about their preferences and what they are open to. I usually start with breathing techniques, although patients with a history of trauma may be resistant to this option. I use box breathing, such as 4-4-4-4 (four-second inhale, four-second hold, four-second exhale, four-second hold). Not everybody is able to do this right away, especially patients with lung disease or heart disease, but they can build up to this practice. Just taking conscious breaths drops a patient’s blood pressure and heart rate (Russo MA et al, Breathe (Sheff) 2017;13(4):298–309). I then explore additional treatment options based on their symptoms and interests.

CGPR: What other modalities do you offer for mood and anxiety disorders?

Dr. Lavretsky: I offer modalities such as acupuncture and sound healing. To reduce stress, I recommend connecting with nature, such as by forest bathing (Editor’s note: For an overview of various CIM therapies, visit: www.thecarlatreport.com/CIM). I prescribe walking barefoot on sand or grass, which simulates a full-body massage. I recommend swimming, especially in older adults with balance problems. I suggest use of natural light and exposure to the sun, especially to improve a patient’s sleep schedule (Scheuermaier K et al, J Biol Rhythms 2010;25(2):113–122).

CGPR: What do you recommend for patients with neurocognitive disorders?

Dr. Lavretsky: We have studied kirtan kriya meditation along with yoga classes in patients with mild cognitive impairment and in women with cardiovascular disease at risk for cognitive decline. It appears to have a “brain fitness” effect and can be helpful if patients are able to engage (Lavretsky H et al, Int J Geriatr Psychiatry 2013;28(1):57–65; Khalsa DS, J Alzheimers Dis 2015;48(1):1–12). In terms of enrichment activities, active therapy is more neuroplastic, although passive therapy still benefits patients. Music can reduce agitation or anxiety in dementia. Listening to music may also reduce stress in caregivers of people with dementia (Lavretsky et al, 2013). Aromatherapy, primarily lavender, can also calm anxiety and agitation associated with dementia.

CGPR: How do you choose among all these options?

Dr. Lavretsky: I go by patient preference. I ask what they have grown up with and what they find helpful; what brings them joy. If I impose my choice on them, they’re not going to do it. As patients age, especially with cognitive decline, it’s harder to learn new information—so I use overlearned, old information. This is also how music therapy is provided in nursing homes. Music therapists ask what music patients grew up with and compose music lists from the era when patients were adolescents or young adults. This is the music patients are most likely to respond to, as it triggers old memories and can act as a trainer to improve memory (Fang R et al, Transl Neurodegener 2017;6:2).

CGPR: Are the effects equal among the different therapies? What would we expect to see in terms of calming down agitation, for example?

Dr. Lavretsky: There are very few studies in that area, so I can’t say that one treatment is better than another. Some reviews using the Cochrane method found mindfulness to be effective for various disorders of aging, reducing depression, anxiety, and stress (Quintana-Hernández et al, J Alzheimers Dis 2023;91(1):471–481). There is some evidence they benefit cognition as well (Madhivanan P et al, Adv Geriatr Med Res 2021;3(3):e210016). The evidence for tai chi is growing in terms of brain imaging and cognition, as much as for mindfulness and yoga (Wayne PM et al, J Am Geriatr Soc 2014;62(1):25–39). The effects are similar, which you would expect with mind-body therapies.

CGPR: Do you recommend intermittent fasting for memory disorders?

Dr. Lavretsky: I do for aging-related disorders, such as Alzheimer’s disease, and biological aging (Longo VD et al, Nat Aging 2021;1(1):47–59). If the patient does not have a contraindication to intermittent fasting (such as diabetes or history of an eating disorder), I discuss the benefits on metabolism and protecting brain health, but also the side effects of hunger and fatigue. I mention that this is not a strategy for long-term weight loss (Zhao D et al, J Am Heart Assoc 2023;12(3):e026484). We then discuss an eating pattern in which the patient does not consume any calories for a certain amount of time.

CGPR: Are there any vitamins or nutritional supplements that you recommend to prevent or treat mental illnesses in older adults?

Dr. Lavretsky: Older adults tend to have nutritional deficiencies because of monotonous diets. They don’t tend to eat the colorful array of vegetables and fruits, lean meats, and fish that are commonly found in the Mediterranean diet and are also recommended by the American Heart Association (Arnett DK et al, Circulation 2019;140(11):e596–e696). I would consult with a dietitian before trying supplements (Editor’s note: See “Nutritional Supplements” table on page 5). I recommend vitamin B complex supplementation, as this may slow cognitive decline. Vitamin D3 is popularly studied for the prevention of cognitive decline, although the causal relationship is inconclusive (Sultan S et al, J Aging Res 2020;6097820). I recommend fish oil to treat mood disorders and to prevent cognitive decline (Saunders EFH et al, J Clin Psychiatry 2016;77(10):e1301–e1308; Huang Y et al, Front Neurosci 2022;16:910977). Depending on symptom cluster, I use other supplements with good data, like S-adenosyl methionine (SAMe) for mood disorders and melatonin and valerian root for sleep.

Table. Nutritional Supplements.
Click to view the PDF

CGPR: Patients often worry that supplements are not regulated.

Dr. Lavretsky: True, so I recommend patients go with respected brands, such as Standard Process or Life Extension. They can also look up ratings on Consumer Reports (www.consumerreports.org) or similar platforms. I suggest they use Costco pharmacies, which typically screen supplements for quality and have reasonable prices.

CGPR: For some supplements, the evidence is mixed. For example, the vitamin D literature suggests that supplementation doesn’t improve outcomes. What’s your take on this?

Dr. Lavretsky: There is no evidence that supplementation in the absence of deficiency provides any benefits. I check for deficiency in people at risk to guide supplementation decisions. For example, if a person has low levels of vitamin D (<20 ng/mL), I supplement. Zinc deficiencies are also common, especially in patients eating a vegetarian or vegan diet. Western medical research that we take as scientific evidence of efficacy tends to study groups using statistical averages that may not reflect individual variation in response. For example, no studies have shown that fish oil is helpful for treatment or prevention of dementia, but that’s on average in large heterogeneous groups that were not assessed for existing deficiencies of omega-3 levels. In order to form an opinion about supplements that may be effective, we have to know the response in those with existing deficiencies. It helps to understand the characteristics of those who respond to supplements (responder analysis) in order to recommend their use to more targeted populations.

CGPR: What have you learned in terms of using CIM in older adults with cognitive impairment as a result of COVID infection?

Dr. Lavretsky: Long-COVID is a model of chronic stress, so I employ what we know about stress reduction treatment for inflammatory disease. Supplements appear to reduce the severity of neuropsychiatric and cognitive symptoms over time. I primarily use supplements such as vitamin B complex, D3, and fish oil in those who are deficient and who can tolerate them. I individualize the use of ginkgo biloba for cognitive symptoms, as it may increase bleeding time and affect blood pressure. As chronic stress requires support for a patient’s adrenals, I use ashwagandha, an adaptogen herb, as well as arctic root (or Rhodiola rosea), which can treat chronic fatigue (Yadav B et al, Trials 2021;22(1):378; Karosanidze I et al, Pharmaceuticals (Basel) 2022;15(3):345). Siberian or American ginseng also have literature supporting their use in chronic fatigue and cognitive impairment (Todorova V et al, Nutrients 2021;13(8):2861). In severe cases I use memantine, as we’ve shown it improves cognition in older adults with depression and cognitive decline (Lavretsky H et al, Am J Geriatr Psychiatry 2020;28(2):178–190). I also use breathing, yoga, tai chi, acupuncture, or Chinese medicine for self-regulation and stress reduction.

CGPR: What’s your experience in treating anxiety and depression in long-COVID?

Dr. Lavretsky: Patients who were previously stable may develop treatment resistance with long-COVID. I often have to start from scratch. They may no longer tolerate SSRIs due to gut sensitivity, or they may develop new food sensitivities.

CGPR: Which CIM resources do you recommend for older adults?

Dr. Lavretsky: The National Center for Complementary and Integrative Health recently announced funding for virtual centers to house CIM resources. We have a similar initiative within the University of California to create a virtual center with CIM resources (www.tinyurl.com/2bsjx633). My website, Integrative Mental Health at UCLA, has breathing videos, exercises for COVID, and lectures about supplements for COVID (www.tinyurl.com/bddtmd7y). UCLA Mindfulness Research Center offers an app and online classes and courses (www.tinyurl.com/mrx8mn5h).

CGPR: Thank you for your time, Dr. Lavretsky.