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Celebrating Mental Heath Awareness Month with Geriatric Neuropsychiatrist Dr. Dilip Jeste

Published May 18, 2022

Show Notes

May is Mental Health Awareness Month as well as Older Americans Month. This critical intersection implores us to explore emotional, psychological, and social-well being as we age. Here to join us for this conversation is Dr. Dilip Jeste, professor of psychiatry and Director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego. Dr. Jeste is a geriatric neuropsychiatrist who specializes in mental health and well-being with age.

Episode Transcript

Sue Peschin: 

Hi everyone and welcome to This is Growing Old, the podcast that’s all about the common human experience of aging. My name is Sue Peschin and I’m the president and CEO of the Alliance for Aging Research. May is Mental Health Awareness Month, as well as Older Americans Month. And it’s an important time to talk about emotional, psychological and social wellbeing as we age. 

Sue Peschin

Here to join us for this great conversation is Dr. Dilip Jeste, Professor of Psychiatry and Director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego. Dr. Jeste is a geriatric neuropsychiatrist who specializes in mental health and wellbeing with age and is one of the Alliance’s favorite people to talk to. Dr. Jeste Dilip, thank you so much for joining us today. 

Dr. Dilip Jeste

Thank you, Sue. It’s a pleasure and a privilege being on your podcast. I’ve had the pleasure of knowing you and Alliance for many years and I have great admiration for what you do. 

Sue Peschin

Well, we’re… Right back at you, so, (laughs), uh, we’re excited too. So you, you have focused a good portion of your work on mental health and wellness across the lifespan. Why do you think this is so important? 

Dr. Dilip Jeste

You know, when we talk about aging, most people have a negative picture of aging. Aging means decline, degeneration, dementia, disease, and death. And that is because people look at aging primarily from physical health perspective. And physical health does decline with age, no question about that. However, that is not the main thing. The main thing is wellness and personal wellbeing, happiness, contentedness. And there is something I call paradox of aging. We did a study of 1500 people from the community from age 20 to 100 plus, and we have been following them for 10 years now and we are looking at physical health as well as mental wellbeing. Physical health, as we all expect, declines with age. Twenties and thirties at the fountain of youth, the best physical health. By the time we reach eighties, nineties, the physical health has declined considerably. However, if you look at mental wellbeing, it goes exactly in the opposite direction. 

Dr. Dilip Jeste

The fountain of youth, twenties and thirties is also a fountain of anxiety, stress and depression, lot of peer pressure, you feel that you’re not doing as well as others, and you’re not sure what you’re going to do. Compare that to people in the seventies and eighties who are much more happy, contented, they are happy with what they have done, and feel lucky that they’re still alive and doing well. Okay, so mental well being really goes in the opposite direction and that is what matters. Ultimately, the purpose of life is happiness, contentedness. And so increasingly, when in medical research, the focus has become wellbeing rather than strictly physical health. 

Sue Peschin

Yeah, I love that. I love hearing you talk about that too. And you also, uh, speak about the wisdom of aging and in fact, you’ve written a book about the wisdom of aging. What do you mean by this and would you f- share some of your findings from your wisdom research and tell us a little bit about your book? 

Dr. Dilip Jeste

Yeah, sure. Thank you. So I, uh, was born and grew up in India, and in many Eastern cultures, older people are respected. They’re thought to be wiser. And I took it for granted, but I never thought much about it until decades later when I become a geriatric psychiatrist and a neuroscientist. And I said, it’s really this… Is this true? Can we empirically show that older people have more wisdom? 

Dr. Dilip Jeste

The first question is what wi- is wisdom. The concept of wisdom has been there particularly from the beginning of humanity. All the religions, philosophies mention wisdom. 

Dr. Dilip Jeste

But empirical research on wisdom started only in the 1970s, started in Max Planck Institute in Berlin, and at University of Southern California in Los Angeles, which has been growing since then. 

Dr. Dilip Jeste

Uh, there, there were 2000 papers on wisdom just in the last decade. So we began doing research on wisdom about 15, 20 years ago. And the first question was, how do you define wisdom? That is critical. Wisdom is a personality trait. It’s a trait like resilience, optimism, introversion, extroversion. It describes a pattern of behavior in an individual. However, wisdom has several components. 

Dr. Dilip Jeste

The single most important component is empathy and compassion. 

Dr. Dilip Jeste

Understanding of this emotions and helping them. Second component is emotional regulation, control over the emotions, not like a teenager who’s emotion fluctuate hour to hour, minute to minute. Third is self-reflection, the ability to look in words, trying to find out what we did wrong and how can we do better. So these are the main components of wisdom. So we have been studying wisdom in, in an empirical way. We developed a scale for measuring wisdom called San Diego Wisdom Scale. Uh, the larger version is 28 items, shorter version is seven item. And anyone of you can access that on, uh, our website, uh, and complete it. And you then get scores for each component of wisdom that I mentioned. Wisdom is biologically based to some extent. It is based in the brain, of course, and we identified specific regions of the brain that are important- 

Dr. Dilip Jeste

… like prefrontal cortex… 

Sue Peschin

Oh wow. 

Dr. Dilip Jeste

Wisdom increases with aging. Not in everybody, (laughs). There are some old people who are very unwise. Some young people are very wise. But by and large, as we all get older, we become more empathic and compassionate. We become more controlling over our emotions, more self reflective. So it does increase with wisdo- aging. But again, as I said, not always, so we have to try. But the last part I want to mention is that, there are ways in each wisdom can be increased. There are randomized, controlled trial that show that we can increase empathy, compassion, emotional regulation, et cetera, through psychosocial, and other means. 

Sue Peschin

Hmm, one thing I have thought about since reading your book is, you know, there’s so much going on today. There’s, you know, a lot of people who are not getting along with each other, right? And you can have, um, compassion and empathy for a lot that’s been revealed, right, about disparities, um, uh, in racial and ethnic communities, uh, attitudes towards people with disabilities, the, you know, talk about rationing when we were in COVID, with ventilators, all this type of stuff, But it… And you can be compassionate and have empathy towards it. But it can also be very upsetting emotionally. And so I’m just, sort of, wondering like, and so in order for, for you to wanna change things, right, that takes a bit of, kind of, passion and almost righteous anger. Um, so how, how do you reconcile all of that? 

Dr. Dilip Jeste

Uh, s- you make a great point Sue, Um, you know, just like there is individual wisdom, there is societal wisdom also. And what has happened to our society in the last two or three decades is that, things have gotten worse. Um, there is considerable more loneliness and social isolation today then there was 25, 30 years ago. And this is actually a pandemic, behavioral pandemic that has been going on. You know, for example, according to CDC, the rates of suicide in the US have gone up by 33% over the last two decades. Rates of s- opioid related deaths have increased tenfold over this period of time. 

Dr. Dilip Jeste

And one of the main contributors is loneliness, social isolation. But also, there is more anger, hostility, depression, stress, the Gallup pulse show that. So there’s no question that things are not going well, and we need to do something about that. And so what is needed at individual level is also needed at societal level. We need to teach people about empathy, compassion, emotional regulation, self-reflection. We typically reward hard skills, reading, writing, arithmetic, uh, in medical school, how to be the best diagnostician and, uh, treatment prescriber. 

Dr. Dilip Jeste

We don’t teach our medical students, or even actually starting from kindergarten, how to be compassionate toward others- 

Dr. Dilip Jeste

… how to regulate our emotions, how to be self-reflective. You know, in sports, we recognize the champions, but we don’t do sportsmanship awards. What we need is more compassionate community and more understanding, and accepting diversity of perspectives. That’s really critically something we are lacking today. 

Sue Peschin

Yeah, I like that. I… So it’s, you know, it’s one thing to have it on an individual level and to try to work to cultivate it on an individual level. But it can be challenging when the society is going in the opposite direction. It’s interesting. Um, so you helped us tremendously with, uh, these mental health fact sheets that we worked on, and we’re very excited to release them this month with the awareness month. 

Sue Peschin

Um, and we’re releasing them on these, uh, topics related to substance use disorders, Alzheimer’s and related dementias, depression, and suicide. Some of these are what you talked about, the, um, diseases of despair. And then we also included Alzheimer’s and related dementias. And these are focused on tips for clinicians to talk with their patients about these complicated and often sensitive subjects. So… And again, you provided the, the, uh, expertise as a reviewer. And so I wanted to dig into those a little bit. So starting with the one on substance use disorders, why are older adults at increased risk? And what can clinicians say to their patients who are dealing with the substance use disorder? 

Dr. Dilip Jeste

Yep. First of all, I want to compliment, uh, Alliance for creating this fact sheets. They’re really terrific, uh, and really very helpful for clinicians as well as for, uh, family members and people suffering from this condition. So substance use disorders are much more common in older people than people think. Uh, there are something like one million Americans, older Americans who have substance use disorders, and they’re often underdiagnosed and definitely undertreated, uh, ’cause people think that older people don’t abuse substances, and that’s not the case. Uh, I said, it is not uncommon, but people attribute that to something else. 

Dr. Dilip Jeste

Uh, and the risk of substances actually increases in older age because older people have multiple physical illnesses. They are on multiple medications for different illnesses. On top of that, they take, um, the supplements, um, o- o- 

Sue Peschin

Right. 

Dr. Dilip Jeste

… over the counter medications and all of these interact and they produce more side effects and more harmful effect in the longer term than in younger people. 

Dr. Dilip Jeste

You know, so what reason why it is more common here? Because the b- this is the baby boomer population getting older. And these baby boomers, when they were younger, they used substances like marijuana or cocaine to reduce the stress. And now in old days, they take… Again, become stressed out. They go back to those, uh, substances. 

Sue Peschin

Right. Yeah, and doctors are also very hesitant to ask about alcohol use- 

Dr. Dilip Jeste

Right. 

Sue Peschin

…. and a lot of drugs interact with alcohol as well. That’s very true. Um, well, I wanna give a shout out to Lindsay Clarke, who is our vice president, uh, senior vice president for health education and advocacy. And she created those sheets and, uh, to thank you for your assistance, uh, in reviewing them. So with Alzheimer’s disease and related dementias, what are some of the behavioral changes that loved ones can expect to see, uh, in many cases, and what are some of the ways that they should communicate with their loved ones when they’re going through those, those issues? 

Dr. Dilip Jeste

This is actually a, a very important question because, uh, Alzheimer’s disease is very common. It’s the most common form of dementia, and the risk of dementia increases with aging. It is often un- underdiagnosed and undertreated. And underdiagnosed because people often confuse, um, any… rescinding of memory with aging only, rather than that, it might be an early sign of dementia. So this is something that should be looked for carefully. So that should be examined by clinicians in their annual wellness visit. 

Dr. Dilip Jeste

So when interviewing a patient, see if the… You are seeing any signs of decline from the previous visit. Ask a patient, ask the caregivers. And if you see something, then it… You can use some screening tools that are available. There are some which are only eight items, uh, scored, uh, there is, um, there is Montreal Cognitive Assessment s- uh, scale that, that can be used. I think it is useful to have them to detect dementia at an early stage, ’cause the earlier you diagnose it, the more you can do. At… And we had to be direct, honest and empathic- 

Dr. Dilip Jeste

…. with patients and the caregivers. This is really important. If they have a diagnosis of Alzheimer, they need to know that. 

Dr. Dilip Jeste

And we also need to document it. We need to document it for the sake of other physicians who are treating other illnesses, like heart disease, or cancer. It is useful for them to know that the person has dementia. And, but just not just a diagnosis. We need to discuss the prognosis. What is the course? And the course is highly variable. Some people can have rapid progression, others will have slow progression. 

Dr. Dilip Jeste

And the symptoms of Alzheimer’s, in addition to memory impairment, are often behavioral. Depression is common. Uh, people become agitated. 

Dr. Dilip Jeste

Um, they sometimes forget that they have eaten. So they may have two dinners- 

Dr. Dilip Jeste

… and sometimes they may not have any dinner for two days. Sometimes they become paranoid. They start accusing their loved one, the caregiver with having affairs or stealing money. It becomes very hard on the caregivers. Being caregiver of a person with Alzheimer’s is very difficult. But there are support groups that are available. So the main thing is that you need to have, uh, clear attitude that this is an illness. It needs to be cared for. There is no cure at this time, but there are ways in which the negative effects of Alzheimer’s can be minimized. 

Sue Peschin

Yes, absolutely. Um, and really good, you know, kind of communication tips and tools around it, so that it kind of ta- will take… help take the stigma away so people can talk about it in a more open way. 

Dr. Dilip Jeste

Right. 

Sue Peschin

Um, so I think all of our listeners understand what a tremendous toll depression can take on an individual and their families. But many people don’t realize that, uh, those who are 65 and older account for 16% of the population, but 19% of the suicides in the US. And there are a lot of contributing factors to this. But one of them is that it can be more difficult to detect depression in older adults. Can you explain why that is, and what clinicians should be doing to better ensure that they’re not missing diagnoses? 

Dr. Dilip Jeste

Okay. That’s a very important point. What happens is that the symptoms of depression such as difficulty in sleeping, not enjoying life, not taking pleasure in anything that they do, um, not eating well, people often attribute those to normal aging or to some stress that they may have, or some situation that they may ha- that may have occurred. But when these symptoms last for a long time, then they deserve a diagnosis of depression. 

Dr. Dilip Jeste

And what is useful to know is that, major depression is less common in older people than in younger ones. But it is the so called subsyndromal depression that is very common. So instead of five symptoms, they may have three symptoms. 

Dr. Dilip Jeste

But even one symptom can have negative impact. So it is really important to check for the symptoms of depression. Again, there are various assessment skills, um, asking the caregivers is important because depression can affect physical health markedly. If people don’t eat well, if they don’t sleep well, clearly that is going to have an impact on their health. Some of the illnesses, they may have like diabetes, arthritis, cancer, whatever. The treatment of those conditions becomes worse with depression, because then you don’t take any treatment. So it is important for others to know that somebody has depression, and at the same time, not feel guilty about it.

Sue Peschin

Mm-hmm (affirmative). 

Dr. Dilip Jeste

It is, it’s not because they have done something wrong. Uh, it is a disease, which can be treated. I think depression is really treatable. Uh, there is no single effective treatment, a- anti-depressants are there, but they take several weeks before they start acting. Psychotherapy is critical. 

Sue Peschin

Yeah. 

Dr. Dilip Jeste

And it can be supportive therapy. It can be cognitive behavior therapy, uh, family therapy, group therapy, whatever it is, but it does play an important role. And some of the depression is preventable. For example, in older people, if you have heart attack, myocardial infarction, or a stroke, you’re much more likely to have depression. 

Dr. Dilip Jeste

So you can start looking for… at a person who just had a stroke or myocardial infarction. You can expect that that person has a higher risk of depression. So you start working with him and the caregivers to detect depression, and to prevent it at that stage. So there’s a lot that we can do with depression in older people. And as you said, the risk of suicide being higher is really something to keep in mind. Um, you know, at one time I remember as a physician, we were told that don’t ask about suicide, it’ll make the person suicidal. 

Dr. Dilip Jeste

That is exact opposite of the truth. Where d- where… If you ask a person about suicidal thought, they will actually admit that, yes, they have been having suicidal thought. And if you don’t ask them, they won’t tell you that. 

Dr. Dilip Jeste

So it is, it is critical that we ask about that, ask about past history of suicidal attempts, family history. If they have some weapons in the house, if they are living in a safe environment, all of these questions are critical for preventing suicides in older people. 

Sue Peschin

Right. Yeah. And I am so glad you mentioned that, like, asking someone if they have had thoughts about hurting themselves, um, is not gonna cause them to have those thoughts- 

Sue Peschin

But it’s a very real question and you generally will get a direct answer back, and it can save someone’s life if you, if you- 

Dr. Dilip Jeste

Right. 

Sue Peschin

…. find that out. Um, so I know we just scratched the surface on a lot of great content and expertise shared in these tip sheets. So I just invite everybody to please check them out in the mental health section of our website at www.agingresearch.org. Before we turn to our more lighthearted question that we ask all of our guests, I just wanna ask you one more question about your work, uh, that ends on a positive note, which is positive psychiatry. Tell us what is positive psychiatry. And what’s one thing we can all do to work on positively improving our men- mental health? 

Dr. Dilip Jeste

And that, that’s a great question. An important one. Um, when I was the APA president in 2012, ’13, one of my jobs was to get the DSM-5 published, and that was important. But DSM-5 is, uh, kind of an encyclopedia of psychiatric diagnosis. But is that all that we do? Psychiatry is defined as a branch of medicine for treating mental illnesses. And I think that is not right. We are, uh, psychiatrist and that applies to psychologists, social workers, nurses, all of them. We, as professionals are not restricted to only treating mental illnesses. Our job is to improve mental health. 

Dr. Dilip Jeste

20% people have mental illnesses, 100% people have mental health. And we need to think about something positive. Our job is not merely to reduce the severity of depression or dementia. Our job is to make people happier. 

Dr. Dilip Jeste

And that is something… So we need to, as clinicians, we need to ask the patient what they like about themselves, what are their strengths? Because those are the things that are helpful in improving their happiness and functioning. And that is positive psychiatry, where we think about not just risk factors, but protective factors. 

Dr. Dilip Jeste

We think about resilience, optimism, wisdom, compassion. Those should be as important as any illnesses that we treat. 

Sue Peschin

Absolutely, I love that. And connection, right? Yo- you know, it’s so important to feel purposeful and connected as we get older. So now to our closing questions, our first one that we ask everybody is when you were a kid, what did you imagine growing older would be like? 

Dr. Dilip Jeste

(laughs), actually, I, I had read a book called Lost Horizon- 

Sue Peschin

Mm-hmm (affirmative). 

Dr. Dilip Jeste

… and, um, written by James Hilton. And it’s a story of people in Tibet, in the Himalayas, and tell you, to the age 200 plus. And they were all very busy, older people, active, et cetera. And for a long time, I thought that was a real, uh, story, uh, based on fact- 

Sue Peschin

(laughs) 

Dr. Dilip Jeste

When, when I found out it was fiction, I was, was very disappointed. 

Sue Peschin

(laughs) 

Dr. Dilip Jeste

But that was the idea of the old age that you not only live long, but you live healthy life and you, uh, are active and you contribute to functioning of yourself as well as other people. 

Sue Peschin

Mmh, and so what do you enjoy most about growing older now? 

Dr. Dilip Jeste

What I do most is actually still learning. I mean, I call myself a professional student. 

Dr. Dilip Jeste

And that’s the fun part. There is always something new to learn. And once you never stop learning. Uh, again, we learn different things at different ages, and different stages. And of course, we can’t learn things that are impossible for us to learn. I mean, I cannot be an engineer tomorrow or computer scientist. But within the research I do, I can do something differently. So… And that should not go away, irrespective of age. 

Sue Peschin

Yeah. Curiosity, all of that. That’s, that’s terrific. Um, and also I’m assuming you still have a st- you still have your ID, right? For- 

Dr. Dilip Jeste

(laughs) 

Sue Peschin

… that was always a big deal, your student ID in school. 

Dr. Dilip Jeste

yes, yes. 

Sue Peschin

(laughs) 

Dr. Dilip Jeste

Right. 

Sue Peschin

So thank you Dilip so much for joining us. It’s just… It’s always great to see you. Uh, and I wanna tell everyone for listening, thank you so much t- for listening to This is Growing Old. If you’re enjoying this show, please subscribe wherever you get your podcast, and hope everybody has a wonderful day. Take care.