Sierra Pacific (VISN 21) MIRECC Clinical - MIRECC / CoE
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MIRECC / CoE

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Sierra Pacific (VISN 21) MIRECC Clinical

Clinical Education
Innovative Clinical Programs and Resources

Ultimately, the MIRECC exists to improve clinical care for Veterans, hence our center does not offer standard clinical services directly to Veterans. Veterans may be eligible to participate in our clinical research projects. For other mental health services, contact one of the convenient VISN 21 facilities for information on eligibility and treatment options. Below are links for clinical research programs in dementia and PTSD.

Dementia

PTSD

Dementia

Dementia Specialized Clinical Programs

Psychotherapy Adapted to Cognitive Dysfunction

PTSD is a form of anxiety disorder but even in civilians without PTSD, anxiety disorders are the most prevalent class of mental health disorders in older adults. Sherry Beaudreau studies how cognitive functioning and impairment are associated with anxiety disorders in older Veterans. She has found that even mild levels of anxiety are associated with lower cognitive performance in older adults. She has been using this work to inform the development of psychiatric behavioral interventions for older Veterans. She has a particular interest in problem-solving therapy for late-life anxiety and leads VA national trainings in this treatment modality.

Repetitive Transcranial Magnetic Stimulation (rTMS)

RTMS is being applied to dementia patients as part of a pilot clinical trial by Joseph Cheng (see Dementia Research).

Obstructive Sleep Apnea and Sleep/Wake Disturbances in AD

Insomnia and sleep apnea are both endemic, poorly treated disturbances associated with aging and have a negative impact on cognitive function. We previously led an NIH Work Group that proposed provisional diagnostic criteria for sleep/wake disturbances associated with dementia. During the current funding cycle, we initiated several projects to bring new clinical treatments to older Veterans with sleep disorders. One of our major efforts was to disseminate Cognitive-Behavioral Treatment for Insomnia (CBT-I) nationwide in the VA system. We have trained over 600 clinicians on this state-of-the-science technique to help treat the millions of older Veterans with insomnia.

Cognitive Behavior Therapy for Obstructive Sleep Apnea

While positive airway pressure (PAP) is an efficacious treatment of sleep apnea, it is not particularly effective given low compliance rates. MIRECC investigator Dr. Lisa Kinoshita has recently received a MERIT award to study CBT for Obstruction Sleep Apnea. This study examines a novel, manualized treatment designed to increase the acceptance of Veterans’ use of PAP for sleep apnea.

Novel Lighting to Improve Insomnia in Older Adults

Jamie Zeitzer recently concluded a VA MERIT grant and is currently conducting multiple studies examining the use of novel lighting to reduce nocturnal arousal in individuals with insomnia, while simultaneously allowing them to safely navigate to the toilet at night.

Clinics

Our center has close relationships with clinical services to enable dissemination and support of innovative programs. A program focused on dementia needs multidisciplinary teams to provide consensus diagnosis. Our clinicians also have expertise and experience with PTSD.

Stanford/VA Aging Clinical Research Center (ACRC)

The Center has performed research in gerontology for over 20 years. The current major emphasis is Alzheimer's Disease and memory losses associated with normal aging. Over the years we have been funded by the State of California, the National Institute on Aging (NIA) and the National Institute of Mental Health (NIMH). Substantial additional resources are provided by the Department of Veterans Affairs (DVA) and the Center is located at the Palo Alto Veterans Health Care System in Palo Alto, California. Learn more.

Memory Disorders Clinic Palo Alto VAHCS

This clinic, led by Lisa Kinoshita, is the major service for geriatric evaluation at the Palo Alto VAHCS. There is also a consultation liaison service led by Steven Chao, behavioral neurologist. Multiple students receive clinical training including several clinical Ph.D. graduate students, a psychology intern, and a postdoctoral fellow. The clinic provides referrals to clinical research projects as well.

San Francisco VA Memory Disorders Clinic

The San Francisco Veterans Administration Medical Center (SFVAMC) is directed by Dr. Kristine Yaffe and offers comprehensive evaluations to veterans with cognitive changes or memory loss.

Clinical Team

Kristine Yaffe, M.D., Lisa Kinoshita, Ph.D., Allyson Rosen, Ph.D. ABPP-Cn, Jennifer Kaci Fairchild, Ph.D.,ABPP, Sherry Beaudreau, Ph.D.,ABPP, Steven Chao, M.D., Joseph Cheng, M.D.

PTSD

PTSD Specialized Clinical Programs

Improving Frontal Emotion Regulation in PTSD by Targeting Sleep

This NIMH-funded project by Dr. Neylan will address whether behavioral treatment of insomnia improves the function of two brain networks involved in emotion regulation – (executive control and extended limbic emotion regulatory systems) by reducing macro- and micro-arousals in REM sleep in PTSD.

Improving Mind/Body Health and Functioning with Integrative Exercise

The goal of this VA RR&D study by Dr. Neylan is to determine if integrative exercise is effective rehabilitation intervention for combat Veterans with PTSD.

Telephone-Facilitated Insomnia Treatment in Primary Care for OEF/OIF/OND Veterans

The goal of VA RR&D funded project led by Drs. Maguen and Neylan, is to determine the rehabilitative utility of a brief behavioral treatment for insomnia for post-deployment Iraq and Afghanistan Veterans who meet criteria for Insomnia Disorder and present for treatment in primary care clinics.

Personalized Pharmacotherapy

In a collaboration between the PTSD Core, and Drs. Williams, Yesavage, and Stanford Psychiatry and Neurosciences, we have developed biomarkers for predicting personalized psychopharmacology focused on antidepressants. Outcomes include: a) the first functional neuroimaging biomarker to predict response among serotonin versus combined action antidepressants, with cross-validated accuracy of over 80%; b) building on the functional neuroimaging biomarker and integrating psychosocial information about early life trauma (a risk factor for depression and PTSD), we found interaction of the emotion-evoked imaging biomarker and early life trauma the most robust and accurate predictor of patients’ response to antidepressants. Importantly, this interaction identified a subset of people who have a trauma history but remain resilient and respond to pharmacotherapy because of their “intact” brain activation for positive emotion; c) using genotyping, single nucleotide polymorphisms (SNPs) that encode for P-glycoprotein and limit the blood concentrations of some antidepressants, we have identified functional SNP rs10245483 as another biomarker for differential prediction. While patients homozygous for the major allele had the best rates of remission on SSRIs, patients with the minor allele are more likely to benefit from a serotonin-norepinephrine reuptake inhibitor (SNRI), such as venlafaxine-XR. We also found that the presence of the minor allele predicted better outcomes for venlafaxine-XR even in older Veterans with poor cognitive status, a significant finding given the current wisdom that poor cognition usually means poor prognosis.

Clinics

San Francisco VAMC PTSD Program

The SFVA PTSD Program is one of the first specialized programs established and is led by Tom Neylan, MD. Staff have extensive experience working with Veterans across a very large age range stretching as far back as Veterans surviving Word War II. Addressing those goals, our PTSD program offers individual and group therapy during weekday and evening hours. There is also an affiliated integrated care clinic integrated care clinic, co-founded by Rina Shah, MD, and Karen Seal, MD, MPH. The SFVA PTSD program fully integrates clinical care, clinical trials research, and education of multidisciplinary trainees.

Clinical Team

Tom Neylan, MD, Shira Maguen, PhD, William Wolfe, MD, Sabra Inslicht, PhD, Anne Richards, MD, MPH, Martha Schmitz, PhD, Brian Mohlenhoff, MD.