SPECIAL REPORT: SCHIZOPHRENIA & PSYCHOSIS

Psychotic disorders are potentially serious and enduring, frequently leading to substantial disability and premature death from suicide or comorbid medical illness. These disorders have been seriously 

in health systems worldwide, even in high-income countries, despite the availability of a range of effective therapeutic interventions and models of care.

 The good news is that better medium-term outcomes are now achievable through early diagnosis and comprehensive early-intervention models of care. Moreover, these outcomes can be sustained, if backed up with high-quality ongoing care to maintain and build on a platform of 

 The challenge is to make this evidence-based and cost-effective approach the new standard of care in the US and globally.

Psychosis is best considered as a range of experiences or symptoms that can develop through the intensification of normal beliefs and perceptions to form delusions or hallucinations, or the acquisition of new and abnormal perceptual experiences or delusional ideas. These constitute what are termed the 

 of psychosis; however, there are other dimensions or syndromes associated with psychotic disorders, notably negative symptoms and mood disturbance.

Psychosis may begin with “orphan” or isolated experiences, but more commonly emerges in the context of fluctuating anxiety and depression, subtle subjective and behavioral changes, and subthreshold warning signs. This pattern, which has been carefully operationalized, represents an earlier, less specific stage—even a pluripotential stage––of illness that already justifies a need for care and attracts additional comorbid syndromes and functional impairment (stage 1).

Once positive psychotic symptoms reach full threshold and are sustained, we can say that the stage of first-episode psychosis (FEP) is now present (stage 2), even if this typically occurs more gradually and dimensionally than is implied by the term, which is to a large extent an artefact of treatment systems. People are allowed to deteriorate to such an extent that a crisis is needed before entry to treatment can be achieved. 

is a heterogeneous umbrella term comprising a range of DSM/International Classification of Diseases diagnoses, including schizophrenia, schizoaffective disorder, brief psychotic disorder, and psychotic mood disorders. It can be seen as a gateway to more traditional diagnostic pathways as well as to remission and recovery.

Staging developed in clinical medicine as a strategy to add precision to diagnosis and treatment selection, and also to prognosis and prediction of outcome.

 Initially a purely clinical approach, it evolved––augmented by biopsy, imaging, and biomarkers––to a more sophisticated clinicopathological approach. Staging is a potentially useful strategy in conditions that have a propensity to persist or recur and lead to worsening impairment and/or premature death. Additionally, it is intimately linked to benefit-risk considerations, embedding the principle “first do no harm.”

Staging is valid when treatments offered in early stages of an illness can be shown to result in better outcomes, but they must be safer than treatments offered in late stages, as the benefit-to-risk ratio changes with illness progression. Remission or stabilization as well as progression are possible at each stage, but remission is usually less likely with each advancing stage, reflecting the interplay with prognosis.

Staging provides the optimal framework for early intervention and a preemptive approach to treatment; the goal is to reduce the risks of progression to later stages. This contrasts with the currently popular notion of stepped care, which is reactive, and only escalates treatment after rather than before a deterioration in clinical status. As such, stepped care represents more of a demand-management strategy than a preventive or preemptive clinical approach.

Biomarkers have the potential to sharpen the precision of staging in psychiatry; however, they are likely to span the traditional syndromal boundaries, which conversely contain heterogeneous biological subgroups. This means a transdiagnostic approach is essential for research and future refinement in staging because current categories are flawed. Transdiagnostic approaches acknowledge the fluid and dynamic nature of the onset and early stages of mental ill health, during which micro phenotypes ebb and flow; they either fade or evolve into a more stable syndrome or macro phenotype or, more commonly, syndromes, because comorbidity is very common (

). Staging has to accommodate this comorbidity and, as such, a transdiagnostic approach that transcends current diagnostic silos is required.

The idea of staging had been proposed earlier in common mental disorders.

 With the early intervention paradigm in psychosis, the ideal conditions existed for clinical staging to be formulated. Psychotic and severe mood disorders were utilized as prototypical disorders for which staging might have the greatest utility.

FEP was the fulcrum around which this began, and an evidence-based case was steadily made that the content of treatment for such cases was very different from what was appropriate for later stages of illness. An earlier clinical stage, the at-risk mental state or ultra/clinical high-risk state, was defined as covering the period prior to the threshold for a first episode of psychosis being reached. This period has become an intense focus for research and intervention.

The validity of these stages was supported by their manifestly different treatment needs and ultimately overwhelming 

that at least progression could be delayed, and early trajectories of illness significantly improved.

 Although some critics remained unconvinced, the mindset of the psychosis field moved from deterministic “doomed from the womb” thinking to a more preventive, recovery-oriented approach, strongly endorsed by patients and families.

A key strength of clinical staging is its ability to guide clinical practice, which is informed by several key principles (

of psychosis there is an earlier stage of illness during which positive psychotic symptoms (eg, distress, mood disturbance, functional impairment), are not dominant.

 During this prodromal stage, treatment consists of needs-based psychosocial interventions, influenced by cognitive behavior therapy (CBT), and a focus on treatable comorbid syndromes such as anxiety and depression, alleviating stress, strengthening coping, and minimizing illicit drug use. Because safer options are effective at this stage, antipsychotic medications are not indicated as first- or second-line treatment, and the benefit-to-risk ratio does not support their use.

Patients with FEP respond much better to all treatments if the duration of untreated psychosis (DUP) is reduced to a minimum. There is varying evidence on the exact window of time for optimal response, but delays of even a few weeks may make a significant difference to treatment response.

 This suggests that FEP might be better considered as a stage with substages within it. In fact, with a much shorter DUP now possible with early intervention, it may be possible for a small subgroup of patients to remit without antipsychotic medication if they are provided with intensive psychosocial interventions alone.

 This might be termed stage 2a. The RAISE (Recovery After Initial Schizophrenia Episode) study shows that specialized early psychosis care may only be more effective than standard care if DUP is not prolonged beyond a certain duration.

 This responsive substage could be designated stage 2b.

Within the first episode of psychosis, the staging approach and research evidence indicate that low doses of antipsychotic medications are effective but must be rigorously adhered to if adverse experiences are to be minimized and engagement maximized.

 Shared decision making has a crucial place here. The imperative to prevent weight gain and metabolic consequences means that medications least likely to produce these effects must be first line.

A subgroup of patients who do not respond to treatment with dopamine antagonists and reveal early treatment failure can be reclassified as a further substage of stage 2, or stage 2c. Alternatively, they can be regarded as having rapidly progressed to stage 4, even within the first 6 months post diagnosis. In this case, the benefit-to-harm ratio changes dramatically, and although clozapine has a number of risks, which means that it should not be used as first-line treatment, the evidence mandates its use early in the course of illness with treatment resistance or as illness rapidly progresses to stage 

Psychosocial treatments, notably vocational interventions such as Individual Placement and Support (IPS) and family interventions, must also be adapted to the stage of illness. Used early and throughout treatment, psychosocial interventions are especially effective at stage 2 in line with what is expected in a staging model and early intervention.

Following the first episode (stage 2), patients may enter stages 3 or 4. Stage 3 interventions involve the prevention of relapse with efforts to prevent and treat comorbidity and persistent subthreshold or residual symptoms of psychosis and other associated syndromes. Long-acting injectables can be seen as a preventive strategy. However, a personalized approach with substages and subgroups reflects a heterogeneity within stage 3. Thus, dose reduction and possible discontinuation are possible for a subgroup of patients.

Long-term follow-up studies reveal that late remission occurs in about 16% of cases.

 Current guidelines for the use of medications are understandably conservative, but patient heterogeneity and response to medications need to be further explored. Later-stage patients who appear to have stabilized, but with continuing symptoms and functional impairment, can be offered a different suite of psychosocial interventions. Interventions specifically linked to this stage can greatly improve patients’ quality of life. These may involve meaningful activity including part-time work, strength-based strategies, social engagement within the community to combat loneliness, family support, financial support, and expert medical care to respond to the greatly increased risk of medical illnesses.

A contributing life is possible for most people and a holistic blend of expert psychiatric, medical, and social care is essential for this to occur. The “soft bigotry of low expectations” is a consequence of poorly resourced systems of care and antiquated diagnostic thinking that is blind to the opportunities that new models of care and high-fidelity implementation can deliver. Such approaches depend on congruent mindsets and conceptual frameworks, and a much more educated and supportive wider community.

Dr McGorry is a professor of youth mental health at The University of Melbourne and executive director of Orygen in Melbourne, Australia. He has received past unrestricted grant funding from Janssen-Cilag, AstraZeneca, Eli Lilly, Novartis, and Pfizer, and honoraria for consultancy and teaching from Janssen-Cilag, Eli Lilly, Pfizer, AstraZeneca, Roche, Bristol-Myers Squibb, and Lundbeck. He has received grant funding from the Colonial Foundation, the National Health and Medical Research Council of Australia, NARSAD, the Stanley Foundation, the National Institutes of Health, and the Australian and Victorian governments.

The Lancet Commission on global mental health and sustainable development

 Correll CU, Galling B, Pawar A, et al. Comparison of early intervention services vs treatment as usual for early-phase psychosis: a systematic review, meta-analysis, and meta-regression. 

Malla A, Joober R, Iyer S, et al. Comparing three-year extension of early intervention service to regular care following two years of early intervention service in first-episode psychosis: a randomized single blind clinical trial. 

Yung AR, McGorry PD. The initial prodrome in psychosis: descriptive and qualitative aspects. 

Clinical Staging in Psychiatry: Making Diagnosis Work for Research and Treatment.

Fava GA, Kellner R. Staging: a neglected dimension in psychiatric classification. 

McGorry PD, Hartmann JA, Spooner R, Nelson B. Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry. 

 McGorry PD, Ratheesh A, O’Donoghue B. Early intervention––an implementation challenge for 21st century mental health care. 

Ajnakina O, David AS, Murray RM. ‘At-risk mental state’ clinics for psychosis—an idea whose time has come—and gone! 

Fusar-Poli P, Salazar de Pablo G, Correll CU, et al. Prevention of psychosis: advances in detection, prognosis, and intervention. 

 McGorry PD, Nelson B. Clinical high risk for psychosis––not seeing the trees for the wood. JAMA Psychiatry. Published online March 11, 2020; Epub ahead of print.

Dama M, Shah J, Norman R, et al. Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis. 

Francey SM, O’Donoghue B, Nelson B, et al. Psychosocial intervention with or without antipsychotic medication for first-episode psychosis: a randomized noninferiority clinical trial. 

 Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program. 

Australian Clinical Guidelines for Early Psychosis––second edition updated. Orygen. 2016. 

www.orygen.org.au/Training/Resources/Psychosis/Clinical-practice-points/Australian-Clinical-Guidelines-for-Early-Psychosis

 Thien K, Bowtell M, Eaton S, et al. Clozapine use in early psychosis. 

Shah P, Iwata Y, Plitman E, et al. The impact of delay in clozapine initiation on treatment outcomes in patients with treatment-resistant schizophrenia: a systematic review. 

Killackey E, Allott K, Jackson HJ, et al. Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial. 

Wunderink L, Nieboer RM, Wiersma D, et al. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry. 2013;70(9):913-920.

Harrison G, Hopper K, Craig T, et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. 

Articles

Psychotic disorders are potentially serious and enduring and have been seriously neglected in health systems worldwide. The good news is that better medium-term outcomes are now achievable.

Stage-Specific Treatment  of Psychotic Disorders

Fears about the overprescription of opioid analgesics and the opioid epidemic have resulted in initiatives for physicians to prescribe these medications more judiciously. However, new concerns about patients needlessly suffering untreated or undertreated pain have been raised.

Unfortunately, many lay people and even many health care providers still believe that opioids are the optimal treatment for all forms of pain and that there are no good alternatives. Studies, however, have shown that nonopioid pharmacologic therapies and nonpharmacologic therapies can be as effective and, in many cases, even more effective than opioids.

and meta-analysis of mind-body therapies (MBTs) for patients whose pain is being treated with opioids highlights how useful these modalities can be and the importance of considering them when caring for patients suffering with pain.

The review included 60 studies with 6404 participants. A variety of MBTs were employed, including meditation, hypnosis, relaxation, guide imagery, therapeutic suggestion, and cognitive-behavioral therapy (CBT) depending on the individual studies. The types of pain varied from procedural pain to burn pain to cancer-related pain to chronic pain. The impact of various MBTs on the pain and on the use of opioids were examined.

The findings indicated that meditation, hypnosis, therapeutic suggestion, and CBT were most likely among the MBTs to provide the greatest pain relief with moderate to large improvements. Meditation, hypnosis, and CBT appeared to have the greatest impact on opioid use. The researchers noted that the lack of evidence for the impact of the other MBTs may reflect that there were fewer studies rather than evidence that those MBTs are less likely to have an effect on either the pain or opioid use.

There were also indications that MBTs may provide some benefit for opioid craving and misuse, another reason why their use should be considered for patients on opioids for whom it is believed these medications should be discontinued.

There were differences between the types of pain for which the individual MBTs were studied. Studies that looked at meditation-based therapies primarily focused on chronic noncancer pain while most hypnosis, relaxation, and imagery studies focused on acute, procedural, or cancer-related pain. Whether this provides any guidance as to which type of therapy would be most beneficial for which type of pain is open to question and warrants further study.

It is worth noting that there is a great deal of overlap between many of the MBTs and what might be considered meditation by some could be considered relaxation or even hypnosis by others, so there is often a lack of clear demarcation between them. MBTs are not a magic bullet for the management of pain. They showed a moderate but statistically significant effect on the pain and resulted in a small but statistically significant reduction in opioid use.

In addition to these apparent benefits, MBTs also have one very significant advantage over many of the other treatments for pain: they are essentially free of adverse events. If they are tried and do not provide any benefit, the patient will be no worse off. As with all the other interventions to manage pain, no one can guarantee that MBTs will provide improvement but one can be as close as possible to certainty that they will not have any negative impact on those being treated with them. If the opioid epidemic has taught us anything it is that therapies initiated to help patients can end up having a destructive effect.

There is one very real limitation in the introduction of the MBTs as major treatments for pain. For the most part, in academic centers and hospitals, pain management is primarily considered to be a subspecialty of a single medical specialty—anesthesiology. The only significant exception to this is headache management, which is usually considered to be a part of neurology.

The reality is that few anesthesiologists and neurologists, even those who specialize in pain management, receive much, if any, training in the use of MBTs, nor do most primary care physicians upon whom the management of pain often falls. Thus, most patients with pain are unlikely to come into contact with caregivers who are knowledgeable about MBTs, much less know how to utilize them.

Obviously, the physicians most likely to be trained in the use of MBTs are psychiatrists, and this is one of many reasons why psychiatrists should be more involved in the care for patients with all forms of pain and not just those patients with diagnosable mental disorders.

There is a need for more and better studies on MBTs for pain. However, this can be said of all the other treatments for it. Let us recall that millions of patients have been prescribed opioids for the management of chronic pain although there are virtually no studies demonstrating their efficacy.

1. Garland EL, Brintz CEE, Hanley AW, et al. 

Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis

This article was originally posted on February 20, 2020, and has since been updated. -Ed

For the millions of patients whose pain is being treated with opioids, mind-body interventions are proving to be important considerations to ease suffering.

Mind-Body Therapies for the Management of Pain: How Effective Are They?

Do you prescribe antidepressants for your patients with bipolar depression? If so, think again, and consider results from the Systematic Treatment Enhancement Program–Bipolar Disorder (

) studies. This was the largest federally funded group of studies of bipolar disorder treatment, and they included important randomized clinical trials involving subsamples of the 4360 patients enrolled.

Among the significant findings were the following:

1. Antidepressants (bupropion, paroxetine) are not more effective than placebo for bipolar depression (24% for the antidepressants versus 27% for the placebo in a 6-month trial).1 The antidepressants, when added to a mood stabilizer, did not induce more switches into mania (10% versus 11%), but the patients who participated in the study were probably at very low risk for switching. However, patients with bipolar depression with mixed features (defined as having 2 or more manic symptoms [eg, agitation and racing thoughts] with their depression) developed manias over the next several months that were more severe as compared with placebo-treated patients.

2. A group of 86 patients with bipolar disorder who responded to an antidepressant when depressed were identified. Some were rapid cyclers (4 or more episodes per year). All of the patients were also prescribed mood stabilizers such as lithium, valproate, or a second-generation antipsychotic. These patients were randomized to stay on the antidepressants or discontinue them. The patients with rapid cycling who were continued on their antidepressant had triple the number of depressions per year compared with those without rapid cycling. Yet, there was no difference in the rate of depressions between rapid and non-rapid cycling in the antidepressant discontinuation group. Thus, depressive morbidity and cycling were worsened by continuation of an antidepressant in patients with rapid cycling.

 were collected on the first 1500 patients looking for evidence of the antidepressant-associated chronic irritable dysphoria (ACID) syndrome described in previous case reports.

 It had been proposed that ACID was caused by treating patients who had bipolar depression with an antidepressant. The patient sample included 63% bipolar I patients with depression; most of the remaining patients had bipolar II. The researchers identified 83 patients in whom a depressive episode developed during the study period and for whom there was at least 1 year of follow-up information. Those who received an antidepressant for their depression had a 10-fold higher risk for ACID than the patients who were antidepressant free. ACID did not seem to occur in the natural course of bipolar disorder; it only occurred in those who received antidepressants.


Findings from STEP-BD studies indicate that antidepressants should be avoided in most cases when treating acute depression in patients with bipolar disorder. Rather, one should choose from among 5 medications with a reasonable evidence-base for effectiveness and safety in treating or at least preventing bipolar depressions, namely: lithium, quetiapine, lamotrigine, lurasidone, and cariprazine—or combinations of these.

 is Associate Professor of Psychiatry, Harvard Medical School, and Consulting Psychiatrist, US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, MA.

1. Sachs GS, Neirenberg AA, Calabrese JR, et al. 

Effectiveness of adjunctive antidepressant treatment for bipolar depression

2007;356:1711-1722.
2. El-Mallakh RH, VÃ¶hringer PA, Ostacher MM, et al. 

Antidepressants worsen rapid cycling course in bipolar depression: a STEP-BD randomized clinical trial

2015;184:318-321.
3 El-Mallakh RH, Ghaemi SN, Sagduyu K, et al.

 Antidepressant-associated chronic irritable dysphoria (ACID) in STEP-BD patients

This article was originally posted on April 24, 2020, and has since been updated. -Ed

Do you prescribe antidepressants for your patients with bipolar depression? If so, think again, and consider results from these studies.

The Case Against Antidepressants for Bipolar Depression: Findings from STEP-BD

Dr Moffic talks about the coronavirus pandemic and the burnout epidemic and what those elements mean psychologically for clinicians. 

The burnout journey goes back all the way to the 1970s, it only applied to the general public at the time. Around the year 2000, the burnout rate among physicians was virtually nil compared with the rest of the workplace and that is because we were more or less in control of what we were doing. But then for profit managed care came to be.

Burnout in the medical industry arose later on with the main symptoms being emotional exhaustion, cynicism, and feeling ineffective. Treatments were ineffective, mainly because it is a systems issue, with oppressive enterprises creating disengaged workers and clinicians and who experienced micro-trauma on a daily basis. Wellness is often discussed to help burnout, but it doesn't do the job because it insinuates the cause of the problem is on us.

During these challenging times, physicians have to be proactive in helping ourselves, especially now that the pandemic is upon us. And that starts now. There are support groups online for physicians if you just want to talk or get advice about how to maintain your mental health, and you can form your own support groups. That is hard principally because we are so busy with our work, but there are ways we can take care of our health. If you find ways to make your system work better, try to share it with other people. We have to do what we can make ourselves safe, make ourselves healthy. 

We also need administrators who actually love us. Love is a strange word in medicine. When I received an administrative psychiatry award in 2016, that is what my lecture was about. On top of everything else, administrators need to love your staff, and medical administrators, love us in our work. That is the only way we can work together in a compassionate and caring way. 

Dr Moffic is an editorial board member and regular contributor to 

 He was a tenured Professor at the Medical College of Wisconsin until he retired in 2012. Since then he has functioned as a private community psychiatrist providing pro bono services locally, nationally, and internationally. Currently, Dr Moffic is focused on four major advocacy initiatives: physician burnout, climate instability, Islamophobia, and Anti-Semitism. He is co-editor of 

Combating Physician Burnout: A Guide for Psychiatrists

 with Sheila LoboPrabhu and Richard F. Summers.

Videos

During these challenging times, physicians have to be proactive in helping ourselves. And that starts now. 

The Paradox of Self-Help

There are moments in history that require us to step back and refocus, to view the issues before us through a new lens and from a different vantage point. We are all now sitting squarely in such a moment.

Trevor Noah, comedian host of the Daily Show, who regularly offers commentary on current events, spoke recently and with a serious tone, setting aside his usual comic repartee. He constructed a narrative in which stories that seem separate—COVID and race, Amy Cooper, George Floyd, the protests, and the looting—are, in fact, connected, the resulting forces surging together to form 

We face multiple interconnected crises: the worldwide pandemic of COVID, the crashing economy and the overarching and crushing impact of systemic racism. And unrelentingly, the climate continues to change and the effects of climate dysregulation continue to roll out and roll on.

 has taken the greatest toll on communities of color; specifically African-Americans, Hispanic, and Indigenous communities. These communities have suffered the greatest number of deaths. These community members are losing their jobs at higher rates than white workers. Black workers able to keep their jobs are often likely to be categorized as “essential” workers in service sector jobs. In such positions, people are often forced to choose between risking their health and trying to maintain the often-tenuous economic security of their families.

We have known for some time that communities of color, often lower income, are exposed to environmental risks at a much higher level when compared to more affluent, white communities. These more vulnerable community members have a higher rate of exposure to environmental toxins and climate-related diseases and the least access to quality health care. These community members are often living in buildings and in locations that cannot withstand the increasing fury of extreme weather events resulting from the changing climate. And yet, because of structural racism, these same communities get the least amount of attention and support to redress these environmental injustices.

As mental health professionals, we have a responsibility to more fully appreciate the corrosive impact of structural racism on individual and societal psyches. Ruth Shim, MD, addressing the social determinants of health, offers a graphic representation of the multiple forces coalescing into adverse mental health outcomes. Of note, climate change is now recognized as one of the social determinants of health.

Perhaps some of us have enjoyed a kind of psychological comfort by keeping safe within our climate silo as we work on issues related to global warming. Is there a degree of protective privilege conferred by focusing so narrowly on climate change? Have we held a kind of hopeful expectation that in focusing just on the climate change part of the equation, it would naturally address the systemic injustices by a kind of ripple effect? That fantasy has been rattled. White, privileged people are positioned in a more “experience distant” manner from both the effects of climate change and racism than are communities of color. The events stemming from George Floyd’s murder have shown us a “here and now,” raw and bleak reality. The curtain has been pulled back, revealing the agony that has been present for centuries and is being expressed again on the streets of American cities. We must hold all things at this painful moment; the pernicious impact of systemic racism, the crisis of the COVID pandemic, and the immense threat of climate change.

Sam Grant, executive director of MN350.org in “

Black Environmentalists Talk About Climate and Anti-Racism

” suggests that we must “help people see the connection between that issue [racism] and the broader climate crisis. . . . So it’s not choosing this or that. Or this, then that. It’s this 

We must change our lens and see how these all weave together: the issues of the pandemic, the economic downturn, structural racism, as well as the degradation of our natural world caused by climate change. The classic figure-ground, vase and profile picture, familiar to us from psychology, is an apt model that allows us to toggle back and forth between a foreground focus upon the impacts of structural racism or upon the environmental crisis. Neither is more prominent or important but together reveal a fluctuating change in perspective. Both must be viewed to make the picture whole.

 captures the potential of this historic moment in a second way. We must focus on the foreground—the tattered and frayed aspects of our society now so harshly exposed. Yet, we must consider the background that is always present in a crisis, the possibility of transformational change. Both must be viewed to make the picture whole.

For climate advocates, we must make environmental justice core to our efforts, while simultaneously holding the awareness that climate change is progressing and threatens the habitability of this planet for us all. The real challenge is to bring new creativity to our efforts and forge multiracial coalitions to address the mental health and public health impacts of inequity, racism, and the climate crisis.

Read Up on the Links Between Racism and the Environment

 Race, Racism, and Mental Health Resources

The Link Between Climate Change, Health, and Poverty

 is in private practice and she is Assistant Professor, Department of Psychiatry, University of California, San Francisco; she is on the Steering Committee of the Climate Psychiatry Alliance. 

 is a staff psychiatrist at the Counseling and Psychological Services of the University of Pennsylvania, and a student in the Masters of Environmental Studies Program at the University of Pennsylvania; she is on the Steering Committee of the Climate Psychiatry Alliance. The authors have no conflicts of interest concerning the subject matter of this article.

1. Conrinthios A. Trevor Noah Relects on George Floyd Protests: “Police in America Are Looting Black Bodies. Yahoo Entertainment. June 1, 2020. 

The social determinants of mental health: psychiatrists’ roles in addressing discrimination and food insecurity

3. Sengupta S. Black Environmentalists Talk About Climate and Anti-Racism. 

On Climate, COVID, and Race

I have seen it all, or at least I thought I had.

But this current financial/health outlier-black swan event is one in which there are no easy answers as to the pandemic’s impact on our world or domestic economies, or the very survival of our health care system.

So amidst this world of unknowns, we share some tips and advice to weather the financial fallout of this storm.

Advice for young and mid-career physicians

If you are in the accumulation phase of your career, nothing has changed. Unless this is the end of our financial systems as we have known them, and that is highly unlikely, the companies in which you have invested and loved are now at fire-sale prices. This makes them good investments, provided you are going to hold them long-term. Just keep saving and investing as you have been.

is the last thing Wall Street wants to see. In fact, uncertainty is the last thing any of us wants to see, especially when it comes to our health or financial security. We have, as a team of financial advisors, witnessed more than 3 decades of ups and downs in the market, and just about every geo-political event imaginable.

But this downturn, as severe as it has been, is something that we have not seen before. It is disconcerting, to say the least, to watch your investment holdings lose up to 30% of their value in one week. However—and, yes, there is a however—even though we have not seen this particular rapid spiral into a bear market and possible recession, we know how things have turned out in the past: things always come back and advance further. This should be no different, since banks are strong and the government is giving its full accommodation to both the virus and the 

We have witnessed firsthand over the years that fear is the most dangerous emotion when it comes to investing. The feeling of watching your portfolio grow each year is pleasant, but it does not match the intensity and pain of watching your investments lose value. Presuming that you had a good financial plan and your exposure to stocks was not more than the absolute minimum risk you had to assume to achieve your financial goals, just stay the course.

You must remember that your stock portfolio represents a long-term strategy; so, do not sell because of fear. Selling after a large decline in the markets is turning a paper loss into a real loss.

Then comes the problem of getting back in before the markets turn upward, possibly as fast as they went down. This is the age of computer trading and things happen very fast, as we have experienced; this particular downturn may well be the fastest and most severe to date. It gave few investors a chance to trim their holdings, since the markets went down considerably in just 1 week.

For those retirement-ready or already retired

For those ready to retire or in retirement, reviewing your budget is essential. Specifically, it may be a good time to divide your expenses between essential and discretionary. Essentials such as food, mortgages, property taxes, utilities, car payments, and the like, must be paid. The discretionary side would be anything not essential, such as eating out, gifts, travel, and so forth. When you calculate the essential and discretionary costs, you can divide each number by your investment net worth, find what the percentage is, and stick to a budget that does not exceed this percentage.

As your portfolio goes down or up, and if the percentage is higher than planned, you may want to cut back on your discretionary spending until the portfolio has recovered. This will preserve principal and address the danger of creating a vicious cycle of depleting your savings when your withdrawal percentage keeps increasing as the portfolio value declines.

There are other strategies to consider. Some examples would be tax-harvesting losses by switching positions on the same day, thereby not missing a possible market upturn, but locking in future loss carry-forwards. Also, repositioning portfolios that previously had too much increase to consider a move because of capital gains. There are many positive moves to consider while we are experiencing these depressed markets.

Of course, it is imperative that you consult with a tax professional before making any changes.

The authors are owners and principals of Grande Financial Services Inc., in Oakhurst, New Jersey.

This article is courtesy of our top-rated sister publication,

Amidst this world of unknowns, the authors share some tips and advice to weather the financial fallout of this storm.

Investing Tips in a Time of Crisis

Dr Pies 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). Dr Pies is the author of several books. A collection of his works can be found on

In the midst of a frightening spike in COVID-19 

 how do we understand those who adamantly refuse to wear protective masks in public? Barring some (very rare) medical contraindication to wearing a mask, I can think of no ethical justification for such a refusal. Given that face masks help prevent asymptomatic spread of COVID-19 and may also 

 of anyone contracting the COVID-19 virus,

 wouldn’t any decent, responsible citizen put up with such a minor inconvenience?

It is tempting to write off the mask refusers as selfish, irresponsible yahoos, or as “COVID deniers”—those who simply don’t believe the pandemic is “real,” or that it represents a serious health threat. There may be some truth to those characterizations. But, in my view, the picture is more complex and provides a window into a cultural archetype that I call the 

 First, though, we need to deal with mask refusal and 

, I referred to a venerable tradition of tough-minded individualism that has marked this country from its very inception.

“The image of the self-reliant, iron-willed “loner” is an iconic American archetype, from the days of the lone cowboy, out on the range, to the novels of Ernest Hemingway. The motto, “

”—which arose during the years of the American Revolution—nicely sums up the feisty spirit of American individualism. Indeed, during recent anti-restriction protests, “

” appeared on numerous flags and banners.”

, this rugged individualism serves as a useful counterweight to the

 impulse—the belief that the community is a “bearer of rights,” to which an individual’s interests may have to be subordinated in some cases. But carried to an extreme—what I called, “hyper-individualism”—the “Don’t Tread on Me” mentality can become an insidious force for societal disintegration.

In my view, many mask refusers are acting out of a debased form of individualism that some would call “toxic masculinity,” and which I would call 

. I hasten to add that I am using the latter term in a broad, generic sense, and 

 as a trait endemic to “Latin” culture or society. A very useful definition of 

“Exaggerated pride in masculinity, perceived as power, often coupled with a minimal sense of responsibility and disregard of consequences.”

In my view, this brand of American machismo helps explain the behavior of many (though not all) mask refusers. In effect, refusal to wear a mask in public settings has become a mark of being “a man’s man”—someone who won’t be pushed around or “muzzled” by governmental “tyranny.” To be clear: I’m not saying anything new here. In April of this year, social scientist Prof. Peter Glick 

“Why the reluctance to model safe behavior? My 

research with Jennifer Berdahl and others

 suggest one critical reason, which is that appearing to play it safe contradicts a core principle of masculinity: 

 In short, wearing a mask emasculates . . . [mask refusers] prove their manhood by showing resistance to experts’ opinions, hypersensitivity to criticism and constant feuding with anyone who seems to disagree with them.”

But, in my view, machismo is just one piece of the puzzle. We now need to examine an archetype that, in academic circles, is called 

—Latin for the “eternal boy” or “eternal child”—and which I want to call, “The American Man-Child.”

“. . . is used in mythology to designate a child-god who is forever young; psychologically, it refers to an older man whose emotional life has remained at an adolescent level . . . He covets independence and freedom, chafes at boundaries and limits, and tends to find any restriction intolerable.”

from an Ohio state representative who refuses to wear a mask:

“I will not wear a mask . . . quite frankly, everyone else’s freedom ends at the tip of my nose. You’re not going to tell me what to do.”

How many frustrated parents have heard, “You can’t make me!” from their petulant, early adolescent child?

 archetype was popularized by the psychoanalyst, Dr Dan Kiley, in his 1983 book, 

The Peter Pan Syndrome: Men Who Have Never Grown Up

. Kiley describes men of this type as follows:

"Narcissism locks them inside themselves . . . pursuit of other people's acceptance seems their only way to find self-acceptance. Their temper tantrums are disguised as manly assertion."

 Now, add in a dollop of magical thinking—as in, “This whole virus thing is a big hoax!”—and we have the makings of the American 

 Tragically, we also have the makings of a resurgent American pandemic that threatens to overwhelm us once again.

 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 

1. Knowles H, Wagner J, Shaban H, et al. Seven states report highest coronavirus hospitalizations since pandemic began. 

https://www.washingtonpost.com/nation/2020/06/23/coronavirus-live-updates-us.

2. Texas A&M University. Face masks critical in preventing spread of COVID-19. 

https://www.sciencedaily.com/releases/2020/06/200612172200.htm

3. Glick P. Masks and Emasculation: Why Some Men Refuse to Take Safety Precautions. 

https://www.psychiatrictimes.com/view/freedom-does-not-mean-being-loose

https://www.britannica.com/topic/machismo

5. Glick P. Masks and Emasculation: Why Some Men Refuse to Take Safety Precautions. 

 April 30, 2020. Accessed June 29, 2020. 

https://blogs.scientificamerican.com/observations/masks-and-emasculation-why-some-men-refuse-to-take-safety-precautions

https://frithluton.com/articles/puer-aeternus/

7. Polman D. Refusing to wear a mask is about the most un-American thing to do right now. Pennsylvania Capital-Star. May 11, 2020. Accessed June 29, 2020. 

https://www.penncapital-star.com/commentary/refusing-to-wear-a-mask-is-america-at-its-worst-dick-polman

The Peter Pan Syndrome: Men Who Have Never Grown Up.

Given that face masks help prevent asymptomatic spread of COVID-19 and may also reduce the chances of anyone contracting the virus, wouldn’t any decent, responsible citizen put up with such a minor inconvenience? Apparently not.

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