James Lake, MD

It is likely that a large percentage of the global population will eventually be infected with SARS-CoV-2 (the virus that causes coronavirus 19 [COVID-19]), resulting in potentially serious health and mental health consequences. An epidemiologic study done in China at the start of the pandemic found that roughly half of adults in the general population were depressed, and 1 in 5 reported high levels of anxiety.

 Individuals who spent the most time on social media websites were almost twice as likely to report depressed mood or anxiety. The crisis is being made worse by a disruption in social support networks during enforced social distancing. Individuals who were already struggling with mental illness before COVID-19 are now facing even greater challenges. These circumstances may worsen in the context of widespread poverty and hunger, entrenched disparities in health care among minorities and the underserved, and an overall decline in access to health care resulting from economic breakdown in the wake of COVID-19.

In the absence of a well-coordinated strategic initiative aimed at mitigating the physical and mental health impacts of COVID-19, a global epidemic of chronic disease, mental illness, and increased mortality may emerge as long-term consequences of stress-induced medical and psychiatric disorders related to widespread unemployment and loss of employer-based health insurance.

 This article will review complex mental health challenges created by the COVID-19 pandemic, address the limitations of conventional mental health care, comment on the potential benefits of integrative mental health care for enhancing resilience and treating specific mental health conditions, and propose a wide-ranging strategic initiative.

Even after antivirals and vaccines are developed and contain the spread of the viral pandemic, a mental health pandemic could go on for years, fueled by anticipated long-term economic and social impacts. High unemployment rates and declining financial security during recessions have been historically associated with increased suicide rates that may continue 5 to 6 years after a recessionary period has ended.

 During the decade of the Great Depression from 1929 to 1939, the suicide rate rose from 13.9 to 17.4 per 100,000. Traumatic memories of surviving years of hardship during the Great Depression resulted in high rates of anxiety and depressed mood for generations. Economic downturns disproportionately affect the lower income segment of the population, which in the United States are predominantly people of color, but all socioeconomic groups are negatively impacted.

 More recently, the Great Recession of 2007 through 2009 led to a significant increase in rates of cardiovascular disease, cancer, and mental health problems, and worsened the ongoing epidemic of opioid and alcohol abuse.

 Based on history, it is likely that widespread unemployment and food and housing insecurity resulting from economic disruption in the wake of COVID-19 will have similar large-scale impacts on health and mental health, especially among low-income workers and minorities.

Neuropsychiatric sequelae of COVID-19 infection

In addition to mental health problems caused by the economic fall-out of the pandemic, emerging research findings suggest that many individuals who become seriously ill with coronavirus infections experience severe neuropsychiatric complications. A systematic review and meta-analysis of 72 studies on acute and long-term psychiatric complications associated with coronavirus infection—including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19—found evidence for delirium in the acute stage of illness, and depressed mood, anxiety, fatigue, and PTSD in the post-illness stage.

 Following recovery from SARS and MERS, over 15% of patients reported persisting insomnia, traumatic memories, mood swings, and impairments in concentration and memory lasting between 6 weeks and 3 years. These findings support a multi-factorial etiology of the mental health impacts of infection with coronaviruses, including direct effects of viral infection on the brain, neuropsychiatric sequelae of cerebrovascular disease, hypoxia and immune-mediated responses resulting in a hyper-inflammatory state (ie, a 

A study done in April 2020 found that a high percentage of hospitalized adults (N=153) with a median age of 71 being treated for COVID-19 experienced neuropsychiatric complications resulting from delirium.

 Cerebrovascular events, including ischemic and hemorrhagic stroke, represented the most common complication, occurring in 62% of patients. Acute alterations in personality, behavior, or cognition was the second most common neuropsychiatric complication, taking place in 31% of hospitalized patients. Almost 60% of individuals with altered mental status fulfilled diagnostic criteria for a specific psychiatric diagnosis. Of the patients with new onset psychiatric disorders, 43% had psychosis, 26% had a dementia-like syndrome, and 17% had a mood disorder. Roughly half of patients who experienced alterations in mental status during hospitalization were aged 60 years or younger. Significantly, 92% reported no previous history of mental illness; however, the authors commented that they were not able to rule out the possibility that psychiatric disorders were present but had not been diagnosed before becoming infected with COVID-19. It is important to note that at the time of writing there are limited data on the acute neuropsychiatric effects of COVID-19, and no data on the prevalence of neuropsychiatric complications in the post-illness phase.

Large prospective studies are needed to determine the prevalence of neuropsychiatric disorders during and following hospitalization for treatment of COVID-19. These will help us to better understand how COVID-19 results in a range of neuropsychiatric complications, to determine how long neuropsychiatric symptoms continue following the acute stages of viral illness, how best to treat neuropsychiatric complications, and to investigate whether those individuals with milder cases of COVID-19 (ie, who are not hospitalized) are at risk of developing similar neuropsychiatric complications.

The direct effects of COVID-19 on brain function are probably compounded by adverse psychological effects such as traumatic memories of intubation and other medical interventions in hospitalized patients, the mental health impacts of prolonged social isolation, anxiety over being infected by a potentially fatal illness, and concerns about infecting others.

Social media: bad, irrelevant, and sometimes helpful

Widespread social isolation in combination with increased reliance on social media for information on COVID-19 may be leading to an elevation in mental health problems globally.

 Due to fake or misleading news reports, many individuals are ignoring recommendations for social distancing, increasing their risk of infection and potentially serious neuropsychiatric complications of COVID-19. At the same time, many are taking extreme measures to avoid any social contact, resulting in feelings of profound isolation, anxiety, and depressed mood. Because of widespread dissemination of unverified or downright fake reports that confuse the public, fear and feelings of loss of control, millions of individuals are relying heavily on social media while sheltering in place. There is growing concern that this trend may result in increased risk of depressed mood, anxiety, PTSD, and other mental health problems.

 Individuals who have recently lost their jobs, ethnic minorities, and the underserved may be at even greater risk.

Although widespread exposure to social media is arguably causing enormous confusion, and worsening already high levels of depression and anxiety, social media platforms can also play important roles during the COVID-19 pandemic. They can educate the public about appropriate safe measures, enhance social support and connectedness, and improve resilience.

 Examples include use of social media platforms to develop and disseminate expert resources aimed at enhancing resilience such as exercise, healthy diet, regular sleep, and engaging in meditation or a mind-body practice.

Call for a strategic initiative and recommendations

Responding to these unprecedented circumstances, in May 2020, the United Nations issued a policy brief: “COVID-19 and the Need for Mental Health Action.”

 The report recommended 3 broad areas of action:

Apply a whole-society approach to promote, protect, and care for mental health

Ensure widespread availability of emergency mental health and psycho-social support

Support recovery from COVID-19 by building mental health services for the future

The COVID-19 pandemic makes the need to address the limitations and inequities of mental health care policies and practices even more urgent. Developing and implementing programs on a large-scale aimed at enhancing resilience and treating individuals struggling with the mental health consequences of COVID-19 deserves the same urgent national and global priority that is being assigned to developing and testing vaccines and antivirals. The highest priority should be given to populations at highest risk, including the unemployed, low-wage workers, African-American individuals, and Hispanic individuals.

 A well-coordinated strategic initiative is needed to restore millions of people to good mental health and will be an essential step in re-starting stalled economies globally and in the United States.

Essential first steps in developing a comprehensive national strategy should include:

Tracking prevalence rates of depression, anxiety, PTSD, and other mental health problems that are taking place in response to the economic and social stresses caused by the pandemic and among individuals who experience neuropsychiatric sequelae following infection with COVID-19

Estimating unmet treatment needs, focusing on underserved populations

Prioritizing treatment of mental health problems that are most prevalent and severe

Developing and implementing a systematic program of interventions and resources that will adequately address needs

The need to re-think limitations of conventional mental health care

In order to be both realistic and effective, a strategic initiative must take into account constraints on mental health care services in the context of a severe economic downturn that has resulted in high rates of joblessness and loss of health benefits among millions of individuals who need care. An equally important and urgent planning task involves identifying those conventional and CAM approaches that are effective, affordable, and widely available for enhancing resilience and treating specific mental health problems. All 3 criteria will be essential in order to successfully implement and scale-up a broad-based national strategy.

Implementing resources that are both effective and cost-competitive calls for a review of limitations of the existing model of mental health care and available conventional treatments of mental health problems. In response to the limitations of the current model of care, in collaborative care patients are seen by a team of primary care providers and behavioral health clinicians who address medical and mental health problems in 1 visit. Studies show that collaborative care is more cost-effective than usual care in all categories measured, including medication costs, inpatient, outpatient, and mental health specialty care, as well as for the management of depressed patients with comorbid, medical disorders, severe anxiety disorders, and serious chronic mental illness.

Although integrative treatment strategies incorporating both CAM and conventional biomedical modalities may initially be costly, downstream savings can be achieved when such integrative strategies yield positive long-term outcomes.

 Systematic reviews of economic modeling studies on compara­tive cost-effectiveness of conventional versus CAM or integrative treatments support that CAM or integrative treatment is cost-effective and may result in cost savings in some cases.

 Finally, higher upfront costs of CAM or integrative health care may be offset by improved work productivity and increased future quality adjusted life years.

The need for effective and affordable CAM and integrative interventions

Many widely used conventional treatments have limited effectiveness, well documented safety problems, and are unaffordable to large numbers of individuals who might otherwise benefit from them, including a growing number of individuals who have recently lost their jobs and no longer have health insurance. Initiatives aimed at enhancing psychological resilience and treating mental health problems should incorporate conventional and CAM approaches that are effective, safe, affordable, and cost-effective. Examples include a regular mindfulness practice for depressed mood, anxiety, insomnia, and PTSD. The National Center for Complementary and Integrative Health is spear-heading a research initiative aimed at investigating non-pharmacologic approaches to stress management in relationship to COVID-19. Topics of specific interest include mindfulness and mind-body approaches that can be used remotely (ie, via apps) to mitigate stresses related to social distancing, and to address deleterious mental health impacts experienced during the active phase and recovery from COVID-19 infection. Other potentially beneficial non-pharmacologic approaches include exercise, nutritional advice, and select natural supplements.

The need for a methodology for developing expert integrative care guidelines

A rigorous methodology for developing expert guidelines for conventional, CAM, and integrative interventions is urgently needed. Along these lines, the RAND Corporation together with the Samueli Institute have developed an efficient and cost-effective approach for conducting expert panels based on work done at the National Institutes of Health Consensus Development Conference and the Institute of Medicine.

 Each expert panel comprises 5 academics and 4 clinicians reflecting equal emphasis on clinical and research expertise. Expert panels use a streamlining approach called Rapid Evidence Assessment of Literature (REAL) to reduce time spent on literature review. The RAND methodology holds promise for reducing costs, improving cost-effectiveness, and reducing time needed to develop integrative protocols addressing the complex physical and mental health needs of individuals affected by COVID-19. This methodology can be equally applied to planning considerations pertaining to biomedicine and CAM modalities and may prove to be a valuable methodology for developing evidence-based protocols in integrative mental health care.

In addition to conventional and non-pharmacologic interventions, the COVID-19 pandemic is an important opportunity for the increasing use of technological innovations in mental health care. Examples include apps, intelligent chat-bots, and digital health platforms aimed at providing personalized psychological support; promoting resilience; and mitigating symptoms of anxiety, depression, insomnia, PTSD, and other mental health impacts of the pandemic.

The essential role of community education

Public education will be an essential tool for conveying accurate information about the role of lifestyle for enhancing emotional and mental wellness. Such health enhancement programs could be widely implemented in the workplace, schools, and communities. Carried out at a community level and coordinated by volunteers, such programs will achieve maximum buy-in and can probably be planned and implemented at little or no cost.

Whole Health Institute recently announced they are spear-heading an initiative to train peer-to-peer whole health coaches. This may be a useful model for a national initiative to train lay-healthcare coaches in every community. It could be emulated in other countries and have a global reach. More specialized programs also need to be developed to address more severe mental health problems such as PTSD, severe depressed mood, and severe anxiety among highly vulnerable populations including the elderly, veterans, and school-aged children.

The need to re-vision social media resources

As previously discussed, social media campaigns can play an important role for disseminating valuable information on lifestyle, enhancing resilience, and providing platforms for communities and health care providers to coordinate planning efforts. Social media interventions have been proven effective for changing perceptions and behaviors on a large scale

, and may become an important part of a coordinated national strategy for psychoeducation and enhancing resilience in the face of COVID-19. The authors of a recently published paper propose that large social media platforms such as Facebook and YouTube should take measures to carefully monitor content to mitigate the negative mental health consequences of fake news, graphic imagery, and inaccurate or distorted posts.

 A coordinated national program aimed at psychoeducation of the general public via social media platforms—even as the outbreak continues—may significantly reduce community spread of infection, enhance resilience, and mitigate the potential short- and long-term psychological impacts of COVID-19.

Successfully implementing an effective mental health care initiative will require shared leadership. It is time for the Department of Health and Human Services, the National Institutes of Mental Health, the American Psychiatric Association, the American Psychological Association, the Institute of Medicine, and experts in mental health care and integrative medicine to join forces and take proactive strategic measures in developing services and resources.

I have argued that a broad range of resources and clinical services are needed to adequately address the anticipated mental health impacts of COVID-19, both for enhancing psychological resilience in healthy individuals and for treating the direct and indirect consequences of the pandemic on mental health. To ensure maximum effectiveness, cost-effectiveness, and availability, the COVID-19 mental health initiative should incorporate both conventional biomedical treatments and alternative approaches, be easily scalable, optimize the role of social media in education and public safety, emphasize community engagement, and be available at little or no cost to millions of Americans who have recently lost their jobs and their health insurance.

is a Psychiatrist in private practice in California and an Adjunct Fellow, National Institute of Complementary Medicine, Health Research Institute, Western Sydney University. His most recent book is

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future

1. Gao J, Zheng P, Jia Y, et al. Mental health problems and social media exposure during COVID-19 outbreak. 

2. Ahonen EQ, Fujishiro K, Cunningham T, Flynn M. Work as an Inclusive Part of Population Health Inequities Research and Prevention. 

3. Brenner MH. Will There Be an Epidemic of Corollary Illnesses Linked to a COVID-19-Related Recession? 

4. Bhugra D, Bhui K, Wong SYS, Gilman SE, Brenner MH. Oxford Textbook of Public Mental Health. In: 

Social class and mental health: The impact of international recession and austerity.

5. Brenner M. The impact of unemployment on heart disease and stroke mortality in European Union Countries. European Commission. 2016. Accessed October 15, 2020. 

https://op.europa.eu/en/publication-detail/-/publication/8e95d2e7-e422-4dd7-bc43-c2dc9f63f6d7/language-en

6. Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. 

7. Varatharaj A, Thomas N, Ellul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. 

8. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. 

9. Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. 

10. Wohleb ES, Franklin T, Iwata M, Duman RS. Integrating neuroimmune systems in the neurobiology of depression. 

11. Amsalem D, Dixon LB, Neria YJJp. The Coronavirus disease 2019 (COVID-19) outbreak and mental health: Current risks and recommended actions. 

12. Neria Y, Sullivan GMJJ. Understanding the mental health effects of indirect exposure to mass trauma through the media. 

13. Merchant RM, Lurie N. Social media and emergency preparedness in response to novel coronavirus. 

14. United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health. May 13, 2020. Accessed October 15, 2020. 

https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf

15. Unützer J, Katon WJ, Fan M-Y, et al. Long-term cost effects of collaborative care for late-life depression. 2008;14(2):95.

16. Katon WJ, Roy-Byrne P, Russo J, Cowley D. Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. 

17. Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. 2012;69(5):506-514.

18. Druss BG, Von Esenwein SA, Compton MT, Zhao L, Leslie DLJAJoP. Budget impact and sustainability of medical care management for persons with serious mental illnesses. 2011;168(11):1171-1178.

19. Grypma L, Haverkamp R, Little S, Unützer JJGhp. Taking an evidence-based model of depression care from research to practice: making lemonade out of depression. 2006;28(2):101-107.

20. Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli RJJoHM. Cost and quality impact of Intermountain's mental health integration program. 2010;55(2):97.

21. Pelletier KR, Herman PM, Metz RD, Nelson CFJE. Health and medical economics applied to integrative medicine. 2010;6(2):86-99.

22. Herman PM, Craig BM, Caspi OJBC, medicine a. Is complementary and alternative medicine (CAM) cost-effective? A systematic review. 2005;5(1):11.

23. Herman PM, Poindexter BL, Witt CM, Eisenberg DMJBo. Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations. 2012;2(5).

24. Coulter I, Elfenbaum P, Jain S, Jonas WJBrn. SEaRCH™ expert panel process: streamlining the link between evidence and practice. 2016;9(1):16.

25. Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. 2016;387(10023):1123-1132.

Articles

While COVID-19 has certainly caused a physical health pandemic, it is taking a heavy toll on mental health too, to the point that strategic action is clearly needed.  

The Mental Health Pandemic Calls for a Strategic Initiative that Emphasizes Integrative Health Care

 asked integrative psychiatrist James Lake, MD, for insights and advice for patients to reduce stress and take care of their mental health on a day to day basis, especially important now when life seems to be in upheaval for so many. It is of utmost importance to focus on improving lifestyle factors, which may then translate into improved general mental health, and more resilience in the face of stress. 

Dr Lake talks about 4 pillars of mental health and health: getting enough sleep, regular physical activity, healthy nutrition, and a practice addressed at stress management.

In order to optimize your mental well being, a healthy diet with the essential nutrients are vital to healthy brain function. Individuals who have healthy diets tend to function better, feel better, and manage better in the face of stress, whether that is day-to-day work stress, or in this case, the extraordinary unprecedented stress that we are all experiencing. Because of the COVID-19 pandemic a healthy diet that includes fresh fish, vegetables, and grains is essential. 

People who engage in regular physical activity tend to feel better and function better. This does not necessarily mean vigorous workouts every day today, but staying active is key. Moderate level of activity might include regular walks (up to 30 minutes or more per day); strength training; using weights; and hiking on the weekends. Nature is always a wonderful way to be active and refreshed, especially during these times of confinement. There is an enormous body of research showing the relationship between regular physical activity and good mental health. In fact, many studies show that individuals who have moderate depression or anxiety or who engage in regular physical activity, including patients who take antidepressants, derive benefit.

A consistent pattern of rest means a patient has enough time to get into deep sleep. This enables one to wake up the next day refreshed, ready go to work or school. Good sleep hygiene entails the things you do from the beginning of your day until the time you go to sleep that night. They will predispose you sleeping better. Try to turn off the television or any other electronics. Students should stop studying at least an hour before going to bed. Don't drink alcohol right before bed and try to avoid it the last few hours of the day. For patients with anxiety disorders, go into a very quiet, peaceful space using gentle yoga or simple mindfulness practice to take their minds off their worries before trying to fall asleep.

People who sleep tend to be more emotionally resilient. In the context of what we are dealing with now, sleep is fundamental to those who are struggling with depression

This can be simple or it can be elaborate, depending on your preferences, or religious or spiritual bearings. Listening to music with earbuds, while also engaged in very relaxing breathing practice can be very calming and can significantly lower your baseline anxiety.

Tools for reducing stress include mindfulness, such as meditation, simple yoga styles that are calming and relaxing, and breathing. Some yoga postures can promote improved sleep, and those should be done at night, an hour or so before bed.

During this time of extreme stress, spiritual practices can help relieve anxiety. Because we don't know what the future will bring, it is particularly important and valuable for people to engage in their spiritual work or to get closer to their religious community, whichever is more personally useful. It can provide enormous peace at to delve into, spiritual practice, which might be meditation and even Buddhist prayer, Christianity or Judaism.

There can be enormous power from thinking more deeply in one's spiritual life. and through affiliation with religious community or fellowship for support and for sharing faith with others. 

A Mental Health Pandemic: The Second Wave of COVID-19

 is a Psychiatrist in private practice in California. His most recent book is 

Videos

Psychiatric Times asked integrative psychiatrist James Lake, MD, for insights and advice for patients to reduce stress and take care of their mental health on a day to day basis.

4 Pillars of Good Mental Health

The COVID-19 pandemic is causing suffering on a magnitude that is unprecedented in living memory. Millions have lost their livelihoods and are struggling financially. Tens of thousands have lost loved ones, and hundreds of thousands who have been infected with the virus face the very real prospect of serious illness or death. The health and financial costs of COVID-19 have resulted in widespread feelings of helplessness and overwhelming anxiety and despair in response to circumstances over which we have little or no control. Chronic exposure to severe stress in the absence of control among countless millions constitutes a perfect storm, with severe mental health consequences on a global scale, including increased rates of depressed mood, suicide, and posttraumatic stress disorder.

Individuals who were already struggling with mental illness before COVID-19 are now facing even greater challenges. After effective antivirals and vaccines have been developed and we have begun to contain the pandemic, the US and many other countries will be faced with a mental health pandemic that will probably continue for years to come. Historically, increases in rates of severe mental illnesses have often followed in the aftermath of national crises. For example, during the decade of the Great Depression from 1929 to 1939, the suicide rate rose from 13.9 to 17.4 per 100,000. Traumatic memories of surviving years of hardship during the Great Depression resulted in high rates of anxiety and depressed mood for generations. Although economic downturns disproportionately affected the health and well-being of the lower income segment of the population, all socioeconomic groups are negatively impacted.

A second wave of the pandemic will be driven by intense feelings of anxiety and despair in a world that is no longer predictable and safe due to high rates of unemployment and homelessness coupled with traumatic memories of surviving one’s own brush with 

 or the death of a partner, parent, or loved one. The personal, social, and economic burden of human suffering, treatment costs, disability compensation, and productivity losses related to mental health problems in normal times have been major public health issues in the US and worldwide. This pandemic has served to amplify the personal, social, and economic costs of mental illness to a magnitude that is unprecedented. It is likely that the mental health consequences of COVID-19 will become the most urgent public health challenge worldwide for decades to come, impacting the well-being and productivity of billions. If left untreated, the psychiatric sequelae associated with the pandemic will have serious long-term social and financial consequences for all areas of human life, including personal relationships, family dynamics, academic performance, and work productivity. 

Developing and implementing programs aimed at enhancing resilience and treating individuals struggling with the mental health consequences of COVID-19 deserves the same urgent priority that is now being assigned to the development and testing of vaccines and antivirals. Large scale proactive measures are a key part of successfully preparing millions of people as they resume their day-to-day lives and livelihoods and is an essential step in re-starting stalled economies on a global scale. In the absence of such proactive measures, COVID-19’s long-term global impact on mental health could easily be as devastating and costly as the financial impact of the virus.

Such large-scale programs must be realistic from a cost perspective. Implementing resources that are both adequate and affordablecalls for a review of limitations of the existing model of mental health care. In the current model of care (so-called 

), individuals with medical problems are triaged and treated by family physicians while individuals with mental health complaints are seen in a different outpatient setting by psychiatrists and psychologists. The result is that individuals who have both medical and mental health problems typically receive care at different times, in different clinical settings, and from different clinicians who often do not have pertinent information about pre-existing health problems and treatment history. In outpatient medical clinics, the priority on efficient triage of medical problems may cause delays in the diagnosis and treatment of serious psychiatric disorders, including major depressive disorder and PTSD, due to the 

 spent screening patients for mental health problems.

Although usual care segregates medical care and mental health services, depressed mood, anxiety, and other common mental health problems are frequently comorbid with medical problems such as cardiovascular disease, lung disorders, chronic pain, and diabetes. In addition, usual care is associated with disparities in the delivery of mental health services to different socioeconomic classes.

In response to the limitations of usual care, innovative collaborative care models are being developed and implemented in outpatient clinic settings. In collaborative care, a team of family physicians (or other primary care providers) and behavioral health clinicians work together using systematic and cost-effective approaches aimed at providing patient-centered care that addresses both medical and mental health problems. Studies show that collaborative care models are more effective than usual care for treatment of mental health problems while simultaneously reducing health care disparities. Collaborative care has also been shown to be more effective for managing patients with chronic mental health problems who have comorbid medical disorders, and is more cost-effective than usual care.

Rethinking mainstream mental health approaches

In addition to improving the existing model of care, we need to rethink current mainstream approaches in mental health care in order to adequately address the mental health impacts of the pandemic. Although psychotropic medications are often effective treatments of depression, anxiety, and PTSD, such conventional treatments have limited effectiveness and safety problems, and they are unaffordable to large numbers of individuals who would otherwise benefit from them. Initiatives aimed at enhancing psychological resilience and treating mental health problems resulting from the pandemic should include non-medication (ie, complementary and alternative medicine [CAM]) interventions supported by research evidence. Examples include a regular mindfulness practice for anxiety, exercise for depression, and select natural supplements known to be safe and efficacious adjunctive treatments of specific mental health problems.

, the National Institutes of Mental Health, the 

, the American Psychological Association, and experts in complementary and alternative medicine to join forces and propose a national strategy for developing and implementing large-scale programs and resources needed to adequately address the growing COVID-19 mental health pandemic. Clinical resources should ideally be implemented following a collaborative care model placing equal emphasis on enhancing psychological resilience in healthy individuals and treating serious mental health problems. In order to be most effective and cost-effective, a COVID-19 mental health initiative should incorporate evidence-based conventional and alternative treatments, and should be made available at little or no cost to the millions of Americans who have lost their jobs and their health insurance.

Urgent need for improved mental health care and a more collaborative model of care, special report

The pandemic has brought about uneasy feelings that can exacerbate mental illness and cause further mental health issues. In its current state, our mental health system is not prepared to deal with what may become a global mental health pandemic, but there are ways to address it.

Millions of people have recently lost their jobs and health insurance benefits because of the 

 pandemic. The result is that many struggling with 

 cannot afford psychotherapy, medications, or other treatments. The economic fallout of the pandemic may continue for years resulting in prolonged unemployment and an increasing percentage of the population with untreated serious mental health problems.

Politicians and state legislatures are debating on how to fill the gap in health care that is a direct result of the pandemic and programs that will provide adequate mental health care for growing numbers of uninsured may take months or longer to implement. The result will be that many people-in the US and other countries-who would receive conventional treatments such as psychotherapy and medications for mental health problems during normal times will not be able to afford treatment, their symptoms may become worse, affecting overall quality of life, relationships, and academic and work performance.

Even when conventional treatment is unavailable or unaffordable for millions of individuals who are struggling with depressed mood, anxiety and insomnia, simple lifestyle choices can make a significant difference. This article is offered as a concise review of the mental health benefits of changes in diet, physical activity, and a regular mindfulness or mind-body practice for depressed mood, anxiety, and insomnia.


	The relationship between diet and risk of developing depressed mood is multifactorial. Findings from epidemiologic studies suggest that individuals who consume whole foods (as opposed to processed foods and fast food diets) are at reduced risk for depression. For example, individuals who closely adhere to a Mediterranean diet, as well as traditional diets in Norway, Japan, and China, which are rich in vegetables and fish, have a 30% lower risk for depressed mood than those with the lowest rate of adherence to a 

 identified 12 essential nutrients that met criteria for antidepressant efficacy: folate, iron, long-chain omega-3 fatty acids (EPA, DHA), magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc.

 Foods with the highest antidepressant food scores (AFS) included oysters and mussels as well as other seafood, organ meats, leafy greens, lettuces, peppers, and cruciferous vegetables such as broccoli, cauliflower, cabbage, kale, and Brussels sprouts.

Deficiencies of select nutrients are associated with increased risk of depressed mood, including certain B vitamins, omega-3 fatty acids, vitamin D, zinc, and magnesium. The B vitamins function as enzyme co-factors that facilitate the synthesis of neurotransmitters implicated in mood regulation such as serotonin, dopamine, and norepinephrine. Foods rich in B-vitamins especially folate, pyridoxine (B-6), and methyl-cobalamin (B-12) may be especially effective against depressed mood. These include whole grains and dark green leafy vegetables. Omega-3s and some B vitamins also have general anti-inflammatory and neuroprotective benefits in the body and brain, which may contribute to their antidepressant effects. Zinc, magnesium and omega-3 fatty acids promote increased synthesis of brain-derived neurotropic factor, which enhances neuroplasticity, resulting in greater resilience of the brain in the face of chronic stress. Increased neuroplasticity may also reduce risk of depressed mood.

 67 individuals with depressed mood symptoms ranging from mild to severe were randomized to a diet support group versus a social support group.

 Individuals in the diet support group received seven individual one-hour sessions and were encouraged to follow diets rich in whole grains, vegetables, fruits, legumes, and low-fat dairy foods. They ate more raw unsalted nuts, fish, lean red meats, eggs, and olive oil while reducing intake of sweets, refined cereals, fried foods, processed foods, and sugary drinks. Individuals in the social support group received the same number of sessions, during which they discussed neutral topics of interest, but did not receive psychotherapy, lifestyle advice, or other interventions. At study end, individuals in the diet support group demonstrated significantly greater improvement in depressed mood scores based on standardized outcome measures compared with those in the social support group.

Dietary preferences also play important roles in anxiety. Generalized anxiety is often associated with reactive hypoglycemia, in which blood sugar drops to an abnormally low level following a meal or drink that contains a large amount of sugar resulting in acute anxiety symptoms that can mimic a panic attack. 

 indicate that individuals who experience heightened anxiety related to reactive hypoglycemia benefit from simple dietary changes including reducing refined sugar and carbohydrate intake, increasing protein intake, and reducing or eliminating caffeine or alcohol.

Caffeine use is also associated with an increased risk of anxiety. Caffeine consumption increases the levels of epinephrine, norepinephrine, and cortisol in the blood, resulting in feelings of “nervousness” in adults who have no mental health history, feelings of increased generalized anxiety, and in some cases, panic attacks in individuals who are predisposed to anxiety or panic. Many individuals with chronic generalized anxiety report a significant reduction in the severity of anxiety symptoms when they abstain from caffeine. Chronic alcohol abuse can also manifest as hypoglycemia and malnutrition resulting in generalized anxiety and depressed mood.

Finally, on a general level, the microbiome-which consists of microorganisms that naturally populate the large and small intestines-may contribute to both physical and mental health through a variety of mechanisms, including beneficial changes in CNS levels of serotonin and other neurotransmitters implicated in mood regulation. The general health of the digestive system modulates immune functioning and brain activity through the microbiome-gut-brain axis. Recent 

 point to a link between imbalances in bowel microflora, increased inflammation of the mucosal lining of the intestines, and systemic immune dysregulation resulting in increased risk of depressed mood.


	Findings from animal and human studies suggest that both the immediate and long-term beneficial effects of exercise on mood are mediated by multiple factors that increase brain levels of mood-elevating endorphins, dopamine, norepinephrine, and serotonin, promote neurogenesis, reduce oxidative stress, and enhance immune functioning.

 Moreover, regular exercise may promote increased neuroplasticity in certain brain regions, resulting in improved mood.

Regular exercise including aerobic and non-aerobic strengthening exercise has 

. Individuals who are less sedentary have a reduced risk of both depressed mood and cardiovascular disease.

 Regular aerobic exercise may also improve cognitive functioning in chronically depressed individuals who often experience difficulties with thinking and memory.

 The results from a meta-analysis of controlled studies (N = 977) of exercise used as a single intervention or in combination with antidepressants support that regular exercise has consistent beneficial effects on depressed mood.

 of studies on exercise as an add-on therapy in individuals with MDD showed that depressed individuals who exercise regularly respond consistently better than individuals who take an antidepressant but do not exercise.

Following a regular exercise program while taking an antidepressant and doing cognitive therapy was found to improve 

 Moderately depressed individuals who exercise in addition to receiving regular CBT are less depressed and report fewer suicidal thoughts compared with individuals engaged in CBT only.

 Antidepressants and exercise probably have equivalent effects on moderate depressed mood.

 The therapeutic benefits of regular exercise may also be comparable to select 

complementary and alternative (CAM) treatments

 of depressed mood such as St John’s Wort (Hypericum perforatum).

Findings of open studies suggest that both aerobic exercise and strength training improve anxiety when done on a regular basis.

 The beneficial effects of exercise on anxiety are similar to those of meditation and regular relaxation. A workout program consisting of at least 20 to 30 minutes of daily exercise can significantly reduce symptoms of generalized anxiety. Findings of a prospective 10-week study of exercise in individuals prone to panic attacks support that regular walking or jogging (4 miles three times a week) reduces the severity and frequency of panic attacks.

In addition to its mood enhancing and anxiety reducing effects, regular exercise enhances self-sufficiency and ensures positive social interactions with other people. Regular exercise has also been shown to improve sleep quality in depressed individuals who do not respond to antidepressants.

 This may be a significant benefit of exercise for general resilience and day-to-day functioning in view of the high prevalence of insomnia in patients who are chronically depressed.

Relaxation, mindfulness, and mind-body practices


	Relaxation techniques include sustained deep breathing, listening to calming music, and progressive muscle relaxation. Examples of mindfulness training include different styles of meditation and guided imagery. Mind-body practices involve both body and mind and include taijiquan, qigong, yoga, and other approaches that involve both the mind and the body. Improved capacity for focused attention and reflection have been proposed as important nonspecific psychological benefits of meditation and mind-body practices. The regular practice of meditation or mind-body techniques such as yoga and taijiquan, may be as effective as CBT or antidepressants for moderately severe depressed mood.

Simple relaxation techniques and mind-body practices also have beneficial effects on insomnia. Mind-body approaches that have been looked at in controlled trials of insomnia include progressive muscle relaxation, massage, meditation, desensitization, guided imagery, autogenic training, and hypnosis. Progressive muscle relaxation and sustained deep breathing are especially effective at reducing sleep latency in individuals with chronic insomnia. Listening to relaxing music soon before bedtime can help individuals with insomnia fall asleep quicker. Many individuals who have problems falling asleep because of chronic worrying report improved sleep with guided imagery.

Meditation and guided imagery are probably more effective than progressive muscle relaxation for situational insomnia but are of little benefit for severe insomnia. Individuals with chronic insomnia who use a cognitive-behavioral technique alone or in combination with a benzodiazepine or other sedative-hypnotic drug report that non-pharmacologic or combined approaches are more effective than medications alone. Improved sleep is sustained longer in individuals who use non-pharmacologic or integrative approaches compared with those who take sleep aids only.

 found that non-pharmacologic treatments of chronic insomnia are initially more expensive and require more time compared with medication management but lead to sustained benefits and are more cost-effective than drugs alone in the long run.


	Finally, I want to emphasize the importance of relationships. In addition to engaging in healthy lifestyle choices, supportive relationships with friends and family members can provide important buffers to day to day stresses and uncertainties that we will continue to face in these uncertain times. Video calls or phone calls can be very heartening and encouraging even when shelter-in-place orders restrict us from direct contact with family and loved ones.

1. LaChance LR, Ramsey D. Antidepressant foods: an evidence-based nutrient profiling system for depression. 

. 2018;8:97-104.
	2. Jacka FN, O’Neil A, Opie R, et al. A randomised controlled trial of dietary improvement for adults with major depression (the “SMILES” trial). B

. 2017;151:23.
	3. Salzer HM. Relative hypoglycemia as a cause of neuropsychiatric illness. 

. 1966;58:12-17.
	4. Cheng LH, Liu YW, Wu CC, et al. Psychobiotics in mental health, neurodegenerative and neurodevelopmental disorders. 

. 2019;27:632â648.
	5. Schuch FB, Deslandes AC, Stubbs B, et al. Neurobiological effects of exercise on major depressive disorder: a systematic review. 

. 2016;61:1â11.
	6. Gourgouvelis J, Yielder P, Murphy B. Exercise promotes neuroplasticity in both healthy and depressed brains: an fMRI pilot study. 

. 2017;2017:8305287.
	7. Schuch F, Vancampfort D, Firth J, et al. Physical activity and sedentary behavior in people with major depressive disorder: a systematic review and meta-analysis. 

. 2017;210:139â150.
	8. Oertel-KnÃ¶chel V, Mehler P, Thiel C, et al. Effects of aerobic exercise on cognitive performance and individual psychopathology in depressive and schizophrenia patients. 

. 2014;264:589â604.
	9. Kvam S, Kleppe CL, Nordhus IH, Hovland A. Exercise as a treatment for depression: a meta-analysis. 

. 2016;202:67â86.
	10. Mura G, Moro MF, Patten SB, Carta MG. Exercise as an add-on strategy for the treatment of major depressive disorder: a systematic review. 

. 2014;19:496â508.
	11. Gourgouvelis J, Yielder P, Clarke ST, et al. Exercise leads to better clinical outcomes in those receiving medication plus cognitive behavioral therapy for major depressive disorder. 

. 2018;9:37.
	12. Abdollahi A, LeBouthillier DM, Najafi M, et al. Effect of exercise augmentation of cognitive behavioural therapy for the treatment of suicidal ideation and depression. 

. 2017;219:58â63.
	13. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. 

. 2007;69:587â596.
	14. Ernst E, Rand JI, Stevinson C. Complementary therapies for depression: an overview. 

. 1998;55:1026â1032.
	15. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts. 

. 2000;29:167â180.
	16. Stevinson, C. Exercise may help treat panic disorder. 

. 1999;4:84-85.
	17. Rethorst CD, Sunderajan P, Greer TL, et al. Does exercise improve self-reported sleep quality in non-remitted major depressive disorder? 

. 2013;43:699â709.
	18. Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. 

. 1999;281:991â999.
	19. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. 

The economic fallout of the pandemic may continue for years resulting in prolonged unemployment and an increasing percentage of the population with untreated serious mental health problems.

Self-Care for Mental Health Problems in the Time of COVID-19

As scientists and politicians debate how and when to 

, there remains enormous uncertainty over the future and a realization that the pandemic is far from over. Some believe that the pandemic may be ushering in a new normal characterized by widespread economic privation, rolling waves of illness and death, and pervasive feelings of loss of control on a global scale. Individuals struggling with mental health problems are especially affected by this pervasive awareness of uncertainty.

It is true that we cannot control the difficult circumstances we are facing-as individuals or as nations-and even near-term predictions by pundits and politicians are modified almost daily. However, we do have the capacity to lessen the intensity of our anxiety and despair in face of the 

 pandemic by changing our internal narratives.

 argues that the degree to which people believe they are in control significantly influences their attitudes toward difficult circumstances, affects resilience, and determines choices of coping strategies. According to the theory, personality styles exist on a continuum with 

 at the other. Individuals with a strong internal locus of control believe that events that happen to them are a consequence of their own choices and actions, whether or not they choose to have control over them (

). On the other end of the spectrum, individuals with a strong external locus of control interpret events as influenced not by their actions or abilities but by circumstances beyond their control. In other words, individuals with a strong external locus of control rely on beliefs in ideas like luck and fate to interpret their experiences. Because individuals with a strong internal locus of control interpret circumstances as being within their ability to control, they are more confident in their ability to influence their future and, hence, more resilient in the face of extreme circumstances. In fact, numerous research studies have established that a strongly held internal locus of control correlates to improved physical and mental health as well as better quality of life.

Interestingly, it turns out that there are regional differences in locus of control; geographic differences significantly influence how populations in different regions deal with natural disasters and other crises. For example, 

 found that a greater loss of life caused by tornadoes in Alabama as compared to that in Illinois was due to more prevalent external personality styles among Alabama residents, who took fewer precautions in face of an impending tornado.

Broad differences in locus of control may also exist between different cultures. For example, ethnic Japanese people and African-Americans tend to be more external. Meanwhile, Whites in North America and Europe tend to be more internal; and findings on locus of control in people of Hispanic origin are ambiguous. All of these differences have important implications for how individuals residing in different geographic regions and in different cultures might be responding to the pandemic and its related hardships. On a large scale, these differences have implications for public health policies, as they may translate into significant regional and cultural differences in numbers of individuals who are directly and adversely impacted by the pandemic (ie, become infected). 

Locus of control theory is a valuable model with important practical implications for understanding how individual responses to the pandemic result in very different outcomes. Those with a strong internal locus of control make choices reflecting their beliefs that their actions play an important role in determining how the pandemic will affect their health and their future well-being, such as maintaining safe social distancing, wearing a face mask, and frequent handwashing. In contrast, those with a strong external locus of control do not believe they have control over their future health in face of the pandemic and are less likely to embrace recommendations aimed at mitigating risk of infection. In other words, a strongly held internal locus of control will expectably result in beliefs and behaviors that could significantly lessen the risk of becoming infected, spreading the virus, or dying as well as abiding by government and medical recommendations.

Although we cannot control the dire circumstances that we are facing, we do have the capacity to lessen the intensity of our anxiety and despair by changing our internal narratives in a world that continues to spin out of control. As we take first steps to re-start the economy, resume our day-to-day lives, and renew normal social contact beyond video calls, we will continue to face unknown risks of infection, and we will continue to share a deep sense of anxiety and despair over economic hardship that will probably last for years to come. In this new normal, choosing to embrace a different narrative-one of internal control-can make a real difference as we continue to face uncertainties.

is a Psychiatrist in private practice in California. His most recent book is 

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future.

Personality, Individual Differences and Intelligence

 (1st ed.). Harlow: Pearson Prentice Hall. 2007.

The tornado threat: coping styles of the north and South

Shifting the internal narrative can enhance resilience.

Resilience and Locus of Control in the Time of Pandemic

This activity offers CE credits for:
	1. Physicians (CME)
	2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

Recent surveys suggest that 7% to 8% of children and 4% to 5% of adults meet ADHD criteria. This CME article provide an understanding of the evidence for the use of complementary and alternative (CAM) treatments for ADHD.