Mary Roessel, MD

We are psychiatrists who are deeply committed to addressing the devastating impacts of climate change on mental wellbeing and its differential impacts on vulnerable minority groups. Some of us came to this project steeped in knowledge and information but from a relatively privileged and comfortable place. The process of bringing together the voices of the various authors in this series, each contributing their rich and varied cultural experiences, has deepened and enriched the awareness of our interconnection.

These conversations have been challenging, but these are some of the difficult conversations we must have as a profession and as a society. Those of us who have been buffered from the devastating impacts of climate change and environmental degradation by our privilege, wealth, and class must recognize that this protection is ultimately an illusion. We are all bound by our shared vulnerability and must face our shared humanity.

We must address racism and climate change together. Hop Hopkins of the Sierra Club 

: “It’s no exaggeration to say that racism and white supremacy harm all of us, because in addition to robbing us of our humanity, racism is also killing the planet we all share." He elaborates by saying, “we will never survive the climate crisis without ending white supremacy …You can’t have climate change without sacrifice zones, and you can’t have sacrifice zones without disposable people, and you can’t have disposable people without racism.”

The articles in this series have highlighted both the tribulations and resiliency of communities of color. In particular, the Indigenous voices speak to the need for rematriation: the renunciation of the current patriarchal, fractured systems and a return to Indigenous wisdom that recognizes the unity between all living beings and the continuity between prior generations and future descendants. This embraces the essential awareness that we are all dependent on the earth as our only sustainable home.

The nonprofit organization Crear Con Salud in Puerto Rico has demonstrated resiliency, community empowerment, and local leadership as it overcomes passive reliance on a distant, unresponsive, neglectful government. Voices from Black communities remind us to confront the hard reality of climate change and its intersection with racism by exposing the daily experiences of communities tarnished by environmental pollutants. The Asian experience opens our eyes to experiences beyond our own borders, challenging our American-centric view. This section underscores both the profound impacts of the climate crisis on Asian countries as well as the huge contribution of emissions by Asian nations. We have much to learn from each other as we move forward.

These varied experiences illuminate our shared burdens. Like a woven tapestry, individual-colored threads bind together in a whole that is stronger than the separate fibers. The challenge is to both honor and acknowledge individual community experiences, and to simultaneously join together in a collective effort.

Climate change is a universal threat endangering the entire world. It is not a problem for any one group but a problem for us all. We must find common ground from our shared values, emphasizing equality, respect, and compassion for all, with a forceful commitment to collective climate action.

An essential step must be to address the current homogeneity of groups combating climate change. We cannot sustain the current situation of predominantly White-dominated climate change groups and BIPOC (Black, Indigenous, People of Color)-dominated environmental justice groups focusing primarily on local issues. Our efforts must establish collaborative ways of working together. As mental health professionals committed to understanding deep emotional wounds and addressing complexities of relationships, we have the tools to assist in bridging the current gaps.

As this series has illustrated, climate change is a devastating existential threat that can also exaggerate pre-existing inequities and health/mental health problems. Yet it also opens the possibility of repairing centuries of embedded structural racism. The solutions that emerge from our shared values must hold to the fundamental principle that climate justice is social justice, and social justice is health and mental health justice. This inevitably will include reparative justice: the possibility of repairing damages inflicted by unequal social, racial, economic structures, and climate disruption.

The Biden/Harris administration has committed itself to addressing both the legacy of our racist history and our reliance on extractive fossil fuel-based economy. One of President Joe Biden’s first actions was to sign an executive order returning the United States to the Paris Agreement. In choosing his appointments, Biden has mobilized stellar leaders who embrace equity, strive to correct massive wealth disparities, and implement climate solutions.

Policies that address climate chance will have either direct or downstream health and social benefits for us all. But particular policies and regulations that have important impacts on communities of color include restrictions on oil and gas drilling on public lands, infrastructure projects with creation of green jobs, emission and toxic exposure regulations, and housing policies including improvements in substandard housing, transportation, and health access. There are signs that the new administration will integrate climate and environmental justice into policy planning across all levels of government, from community and local to state and national.

The business community is also moving forward, with several large corporations setting goals for carbon neutrality. Since a large percentage of emissions are due to the transportation sector, the dramatic steps taken by the domestic and foreign auto industry—setting net-zero carbon emissions goals and shifting production to electric vehicles—is 

 Other businesses are following suit, with Apple leading the way by pledging carbon neutrality by 2030. Additionally, Apple sustainability leader, Lisa Jackson, MS, is spearheading climate justice initiatives by putting equity and climate justice at the forefront of programs directed to support Black and Brown 

 Business leadership at this level can set the stage for others to follow.

Additionally, the growing attention to creating sustainable operations within the health delivery system is one of the ways of getting 

Mental health care professionals have important roles in creating solutions. The following recommendations are numerous and applicable across many domains. No one action, plan, or policy can address the enormity of the problems, but all in combination could decisively improve the future prospects of our communities.

While direct patient/individual recommendations are essential, climate change and the associated racial inequities are not individual issues. They must be addressed at broader systemic and community levels.

. It is important for us to examine and process our own feelings and confront our implicit biases about race, cultural differences, and climate. This is not a fleeting look but requires consistent self-reflection.

To care for diverse patients, we must incorporate culturally and linguistically appropriate material for patients with specific emphasis on climate-related mental health threats. Clinicians should integrate assessment of risk into discussions with our patients before predictable climatic events. The newly created 

 project is one attempt to expand the network of therapists and empower them to address climate related emotional issues (

We must develop ways to assist the growing group of individuals struggling with climate-related emotional difficulties and eco-distress experiences. We can offer our shared knowledge and emotional support skills and strategies. These include emotional regulation tools, group emotional supports, and integration of nature-based engagement activities into clinical suggestions for calming and sensory-affective modulation. This is particularly important for children, both for emotional regulation and to instill a sense of stewardship of the natural world.

Community/systems of care/public health model

. Our mental health system does not have the capacity to meet the increasing needs posed by climate change. We need to rethink our systems of care, expand, upon the current one-to-one treatment approach, and develop new models that focus on building the skills, resources, and social connections that are essential to prevent extensive psychological, emotional, and behavioral problems associated with climate disruption. This paradigm shift is founded on the awareness that emotional and psychic responses are not solely an individual issue, but are derived from real economic-political problems that call for social change.

There are many ways to lend emotional support to those who experience the inequities and racial disparities of the climate crisis. The Groundswell Climate Collective (GCC) is one such creative project that can be a model for 

 The GCC is committed to sharing the voices of people of color and developing community resilience. They utilize visual arts, writing, poetry, and other creative projects in efforts to prioritize youth engagement.

Additionally, we must develop collaborative relationships with other health providers, especially primary care, pediatrics, and obstetrics/gynecology. Psychiatrists can also serve as consultants and resources for paraprofessional and community leaders.

Table 2. Community and Climate Justice Groups

Fostering resilient communities is essential. Resilient communities are networks of local groups that develop emotional support and enhance community empowerment. Community Resilience relies upon strong social networks and attachments, a spirit of cooperation and altruism, trusted community leadership, and strong partnerships among schools, community organizations, faith groups, and health institutions. Providing adequate resources is essential, especially for underserved communities, and may require advocacy for funding sources (

Public health advocacy and policy: a call to action.

 There is no time to waste. Increased global temperatures have risen annually since mid-20th Century, and the polar ice caps are melting at an 

 Since the impacts of climate change on mental health are substantially influenced by social factors, influencing outcomes requires engagement in public policies. We must advocate for better governmental regulations, new laws, and funding of governmental and institutional activities as well as collaborative international agreements and treaties aimed at stopping climate change and eradicating racism.

Our professional organizations must be our voice in advocacy. Professional organizations can provide the tools and training to develop advocacy skills, and their political action committees can advocate for climate-friendly policies directly. Taking an important step, the American Psychiatric Association (APA) has recently allocated resources and attention to the climate crisis, establishing the Committee on Climate Change and Mental Health. However, there is more work to do. We must connect our organizations in order to strengthen our movement and increase its effectiveness.

Table 3. National Health and Climate Groups Committed to Equity and Environmental Justice

There are many national health organizations that focus on climate change and health with an equally strong commitment to addressing environmental justice, equity, and the impacts on vulnerable populations (

We began this series with the Persian poet Saadi’s words, which is inscribed on the United Nations Building. They remind us of our duties to each other we mobilize to address structural racism and climate change.

The sons of Adam are limbs of each other,

Having been created of one essence.
When the calamity of time affects one limb

The other limbs cannot remain at rest.
If thou hast no sympathy for the troubles of others
Thou art unworthy to be called by the name of a human.

Climate change and structural racism threaten us all. We must recognize our interdependence and interconnection with the entire world population and join collectively to face this existential threat. It is through effective collective actions that we can create a more fair, equitable, and sustainable future for ourselves, our children, and our grandchildren.

is clinical associate professor in the Department of Psychiatry at the University of California, San Francisco.

is in the psychiatry and behavioral sciences in the Vanderbilt University Medical Center. 

is Clinical professor of psychiatry and behavioral sciences at the University of California, Davis, and received the Kung Po Soo Award from the APA in 2015 for contributions to understanding Asian American patients with mental health issues. 

is the Asociación Puertorriqueños en Marcha Medical Director, a University of Pittsburgh Medical Center attending physician, and President of the APA Hispanic Caucus.

is a practicing psychiatrist at Garnet Health in New York. 

is a child and adolescent psychiatry fellow at Northwell Health. 

is a psychiatry resident at Garnet Health Medical Center in Middletown, New York.

 is the first woman Navajo psychiatrist to provide Indian Health Service clinical care in New Mexico and a Distinguished Fellow of the American Psychiatric Association. 

is Chairman of the Department of Psychiatry at Garnet Health Medical Center and is on the editorial board for Academic Psychiatry.

To see more on race and climate change, see 

The Tangled Roots of Racism and Climate Change.

General motors intends to lead the auto industry and the world to a net-zero-carbon future

. LinkedIn. January 28, 2021. Accessed May 7, 2021. 

. Climate.gov. March 15, 2021. Accessed May 7, 2021. 

Articles

Climate change is a devastating existential threat that can exaggerate preexisting inequities and health/mental health problems. As mental health professionals committed to understanding deep emotional wounds and addressing complexities of relationships, psychiatrists have the tools to assist in bridging the current gaps. 

Next Steps

I acknowledge I am living and working on the ancestral homeland of the Tewa people; on the place called, Po’oge, Whiteshell place. I recognize the ancestors and present-day Tewa people have loved and cared for these lands for centuries. I am honored to be a guest on this territory.

Indigenous peoples around the world have lived in harmony with the land, animals, plants, and cosmos on their ancestral territory for thousands of years, since before contact with settlers. The Indigenous peoples were the original caretakers of the land, and their ceremonies, language, medicines, culture, values, and laws are in the land.

Turtle Island, the name of what was later to be called 

, was home to more than 35 million Indigenous peoples before contact with European settlers. After contact, their numbers dwindled to 2% of the United States’ population.

 Genocidal practices, pandemics, and forced relocation to reservations contributed to the drastic reduction of the Native American population.

In 1095, the Catholic Church gave Christian crusaders permission to take the land from any nonbeliever under the Papal Bull “Terra Nullium.” These Papal Bull doctrines continued until 1500 and gave permission to not only take land, but also to take slaves and gold. Similarly, they awarded occupying countries the right to take over and claim lands as their own. During the colonization of Turtle Island, the Papal Bulls—labeled as 

—were used to justify actions of land expropriation. Indigenous peoples lost most of their lands from 1492 to the mid-1800s.

This was just the first of the racist and genocidal practices upon which the colonization of Turtle Island was founded. In 1823, the Doctrine of Discovery was incorporated into US law,

 which allowed land rights to be determined by the US government.

Many other US policies in the 1800s allowed settlers to dislocate the indigenous population. The Indian Removal Act in 1830 authorized the forced removal of Indigenous peoples from ancestral lands east of the Mississippi River and onto reservations. Manifest Destiny, which was enacted by the US government in 1845, justified taking any land west of the Mississippi River. The Allotment Act allowed ancestral homelands to be divided and assigned to Indigenous peoples, even though Indigenous people viewed themselves not as owners but as part of, and caretakers of, the land. This was a foreign concept to European settlers, who considered it a primitive notion. Most Indigenous groups derived their culture, ceremonies, laws, and medicines from the territory on which they lived. Removals and purchases were done in underhanded and deceptive ways by settlers who were intent on extracting natural resources, resulting in Indigenous peoples losing access to ancestral territory and resettlement on unfavorable lands. This impacted their capacity to practice their traditions, culture, ceremonies, and lifestyle. This was a form of cultural genocide and the foundation of the current racism toward Indigenous peoples.

Written into the language of these laws and bills was the idea that Indigenous peoples were heathens, who lacked intelligence and needed others to make decisions on their behalf. Indigenous children were forcibly removed from their families to attend White, Christian boarding schools under the US Statute on Indian Reform in 1906. Food rations were withheld from families that refused to relinquish their children. Captain Richard Henry Pratt, founder of Carlisle Indian School, is quoted: “Kill the Indian in him and save the man.”

More than 6000 Indigenous children never returned home, and parents were not notified of their whereabouts until investigations years later revealed many deaths.

Lands rich in oil, gas, and minerals were acquired without consultation with tribal leaders. In 1955, the Army Corps of Engineers selected the Big Bend dam site near the Lower Brule Sioux reservation in South Dakota to avoid flooding the state capital, which resulted in flooding reservation communities and forced relocation. They did so without authorization from tribal councils.

Relationships with American Indians were assigned to the Department of War and later Department of Interior, creating an antagonistic, paternalistic relationship. There was blatant disregard for First Peoples’ reliance on their territory and sacred lands to sustain their spiritual practices and culture. Indigenous peoples were, and continue to be, dominated by colonizing culture. Indigenous people bear the brunt of imposition of foreign economic systems, concepts of land ownership, and government structures—all racist practices.

The Global Assessment Report on Biodiversity and Ecosystem Service projects that Indigenous groups around the world will suffer much more than the populations of industrialized nations in the climate crisis.

Indigenous communities are particularly vulnerable to the effects of climate change because the creation of reservations and forced relocation of the tribes onto less desirable lands. Many Indigenous communities are located in areas already experiencing early impacts of climate change; some are located along the coasts with sea level rise intrusion, or mountainous areas located near melting glaciers, or areas above the Arctic Circle with permafrost melting. Some of these Northern areas have already experienced some of the most extreme temperature increases, with as much as 4 degrees centigrade (39.2 degrees Fahrenheit) increases documented. These gradual climate changes have profound effects on species demise. It also have impacted the migration and feeding of the caribou, on which many of the Inuit and Sami people depend for their subsistence lifestyle.

On the coast of the Chukchi Sea in northwestern Alaska, Kivalina has been the village home of the Inupiaq peoples for thousands of years. A study assessing climate change impacts on this village showed significant impacts on the community. Warming temperatures have contributed to erosion of the coastline and increased flooding. Permafrost and sea ice continue to melt, causing sea levels to rise. This results in less successful hunts of walrus, whales, seals, and caribou, which impacts food supplies. In addition, severe flooding in 2007 forced evacuation of many of the village residents.

Despite being adaptable, resilient, and resourceful people, the Indigenous populations are bearing the immediate consequences of climate change, which are requiring permanent and drastic changes to their way of life. These factors have impacted the mental health of Inupiaq people.

The US and Canadian governments have given oil and gas companies carte blanche for resource extraction on Indigenous and government lands at the expense of the Indigenous tribes. Abuse and genocide are commonplace at extraction locations existing within and next to Indigenous communities.

 Meanwhile, man-camps and boom-towns housing workers are often located in close proximity to Indigenous communities. The workers making high salaries are often non-Indigenous with little at stake in the host Indigenous communities. The camp environments have been known to increase rates of drug and alcohol use as well as violent crimes like sexual offenses, domestic violence, and have promoted a sex industry.

Indigenous women and girls are disproportionately affected by the violence, substance abuse, and sexual trafficking with little policing in these remote locations. Indigenous women and girls have a murder rate 10 times the national average, and they face greater rates of physical and sexual violence than all other racial and ethnic groups.

 In 2017 alone, there were 5700 reports of missing and murdered Indigenous women and girls (MMIWG).

Melina Laboucan-Massimo is an Indigenous climate change activist; her sister is among the hundreds of MMIWG in Turtle Island. She stated: “Resource extraction is predicated on systems of power and domination, and the system is based on raping and pillaging Mother Earth, along with violence against women. The 2 are inextricably linked.”

Standing Rock’s protest encampment in 2016 was established to protest the Dakota Access oil Pipeline (DAPL). This pipeline was being built in violation of treaties signed between the US government and the Standing Rock Sioux near the Missouri River. It grew into a large act of Indigenous resistance against resource extraction. The protesters called themselves Water Protectors because they were protecting their source of drinking water. They felt this was the last resource since water is life: Mni Wiconi (Water is Life).

Standing Rock Sioux women leaders started the resistance against DAPL by demanding respect for treaty obligations and the sovereignty of the Lakota people. The protest encampment, Oceti Sakowin, grew into a large Native-led traditional encampment and drew thousands of people. Members of the police force and army attacked peaceful Indigenous water protectors, many of them elders and spiritual leaders.

 Marches and rallies near the encampment, as well as all throughout the country, supported this direct action against building the pipeline. This sustained protest created a wave of support for Indigenous sovereignty throughout Turtle Island from numerous non-Indigenous peoples. It also elevated the awareness of Indigenous rights and the shared investment in protecting Mother Earth.

There will be more protests and acts of solidarity for Indigenous resistance against extraction economies as we fight for a rematriation and reclaiming of Indigenous lands by the first peoples. “Rematriation” is the return to a spiritual way of life with respect to Mother Earth. We need to move away from the patriarchy that has perpetuated the stealing of Indigenous lands, the harming of Mother Earth by extracting natural resources for profit, and fostering the dependence on fossil fuels. Reversing this can lead to climate justice.

Additionally, efforts to reclaim ancestral lands and to restore control of resources and reduce dependency on the dominant culture is a major focus of the Land Back movement.

President Joe Biden’s pick for Secretary of the Department of Interior, Debra Haaland, is the first Indigenous leader to be a Presidential cabinet appointee in US history. She supports the protection of sacred ancestral homelands of Indigenous peoples, as well as moving away from dependence on fossil fuels. She knows first-hand the negative impact resource extraction. We are witnessing the needed shift in addressing the climate crisis, by rejecting patriarchal values and focusing on healing Mother Earth for the seventh generation—the obligation to preserve Mother Earth for the future seven generations to come. New policies must be sustainable and embrace the notion that the earth is not just our current home but also must be protected for our descendants.

Indigenous people’s voices continue to be muted in broader American society. This is sad but also foolish. Knowledge brought by first nations is broad, including agricultural methods that sequester carbon, and principles of reciprocity and harmony with nature modeling a unique relation to Mother Earth. Indigenous knowledge can be substantial part of resolving the climate crisis. We must find ways to elevate Indigenous voices and benefit from their wisdom.

When the beauty of the sacred comes on earth, there will be restoration of universal harmony.

is the first woman Navajo psychiatrist to provide Indian Health Service clinical care in New Mexico and a Distinguished Fellow of the American Psychiatric Association.

1. United States Census Bureau. 2017 Data Release New and Notable. Accessed April 14, 2021. 

https://www.census.gov/programs-surveys/acs/news/data-releases/2017/release.html

Groundswell: Indigenous Knowledge and A Call to Action for Climate Change. Strong Nations

3. Native Peoples’ Concepts of Health and Illness. 1823: Supreme Court rules American Indians do not own land. Accessed April 14, 2021. 

https://www.nlm.nih.gov/nativevoices/timeline/271.html

Indigenous Peoples’ History of the United States

5. History Matters. “Kill the Indian, and save the man”: Captain Richard H. Pratt on the education of Native Americans. 2014. Accessed April 14, 2021. 

6. IPBES: Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services. Home Page. Accessed April 14, 2021. 

7. Clayton S. Climate anxiety: Psychological responses to climate change. 

8. Brubaker M, Berner J, Bell J, et al. Climate change in Kivalina, Alaska: Strategies for community health. Alaska Native Tribal Health Consortium Center for Climate Change and Health. January 2011. Accessed April 14, 2021. 

https://www.cidrap.umn.edu/sites/default/files/public/php/26952/Climate%20Change%20HIA%20Report_Kivalina.pdf

9. National Inquiry into Missing and Murdered Indigenous Women and Girls. Reclaiming power and place, Volume 1a. 2019. Accessed April 14, 2021. 

10. Coalition to Stop Violence Against Native Women. MMIWG2S. 2020. Accessed April 14, 2021. 

11. State of New Mexico Indian Affairs Department. New Mexico missing and murdered Indigenous women and relatives task force report. December 2020. Accessed April 14, 2021. 

https://www.iad.state.nm.us/wp-content/uploads/2020/12/NM_MMIWR_Report_FINAL_WEB_v120920.pdf

: Standing Rock Versus the Dakota Access Pipeline, and the Long Tradition of Indigenous Resistance.

Respect for Indigenous peoples and their knowledge is crucial to the resolution of climate change. 

Recovering Ancient Knowledge for the Good of the Earth

[[{"type":"media","view_mode":"media_crop","fid":"22570","attributes":{"alt":"","class":"media-image media-image-right","height":"186","id":"media_crop_1433478246362","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1645","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image","width":"126"}}]]It is important to appreciate and understand the current problems and significant limitations of the present approach to psychiatric therapy before considering new directions. The largest problem is that while there is ample evidence of the limited long-term benefit of psychiatric medications, psychiatrists are pressured to be psychopharmacologists instead of psychotherapists. Psychiatrists are influenced by the pharmaceutical industry, which makes enormous profits from psychiatric drugs. In addition, psychiatrists are under pressure by insurance companies that pay more for 15-minute medication checks than for effective psychotherapy treatments.

 has been used successfully for psychotherapy, yet many programs stress evaluation and medication management. At the same time, psychiatrists are not providing care using treatments for which significant progress is being made, such as cognitive processing therapy, eye movement desensitization and reprocessing, mindfulness-based therapy, and short-term psychodynamic psychotherapy, to name a few.

Research on pharmaceuticals over the past 20 years clearly demonstrates the limited benefits of medications, particularly in the long term; there is growing concern that the harm is likely to outweigh the benefits. Even for short-term depression therapy, STAR*D findings suggest that only about 30% of patients have complete depression symptom remission with active treatment.

 The CATIE trials showed that overall improvement in therapeutic benefit with new-generation neuroleptics is minimal compared with older drugs and that significant symptom remission appears to be a very difficult therapeutic target.

Recent research on the pharmacotherapy for ADHD shows that the initial results fade over time and that the medications may do more harm than good.

 Recent research on benzodiazepines and new hypnotics suggests that they may increase mortality as much as smoking cigarettes.

 It has been known for a long time that the mortality rate in patients with schizophrenia far exceeds that of the unaffected population. Dose reduction or discontinuation of antipsychotics during the early stages of remitted first-episode psychosis achieves long-term recovery rates superior to those achieved with maintenance therapy.

 This finding clearly goes against recommendations that schizophrenic patients have to continue taking medications long-term to prevent relapse. While there are some medications that have a role, such as carefully supervised lithium therapy for bipolar disorder, basing the future practice of psychiatry on medications is a folly.


Psychiatric practices tend to be referral-based. The initial diagnosis is made by a primary care physician (PCP), and patients have already undergone 2 or 3 medication trials before they are referred to a psychiatrist. As such, the chances that the patient will respond to medications decreases. Many patients are in the 50% subgroup who do not respond adequately to medications. When the psychiatrist sees these patients, he or she needs to determine-often in a single visit-whether there have been adequate medication trials, whether other diagnoses have been missed, and whether medical or nutritional issues are affecting treatment. The psychiatrist’s training and experience are often needed, as well as time and financial support, to address complex cases.

In developing new directions, it is important to first “do no harm.” If possible, we must focus on finding more effective, less harmful therapies than medications. For example, exercise may work as an antidepressant for some patients.

 Exercise has risks, but it also has many health benefits. Using motivational therapies to assist patients in making changes we know to be effective can provide significant health benefits and might replace ineffective medications in treatment-recalcitrant patients.


The current practice of psychiatry is so focused on medications that other potential approaches have been neglected. Nutrition, for example, has not been a significant aspect of psychiatry and yet people who eat a Mediterranean diet or greater amounts of fruits and vegetables have been shown to have significantly less depression than a comparative population of those who eat a standard diet.

 Further research is needed to explore potential approaches to psychiatric treatment, other than medications.

The best research can only give us a general direction. It does not tell us what to do when treating each patient. Even with a simple, straightforward case, the patient’s general medical condition, motivation, family support, basic belief systems, and culture must all be considered. Diagnostic possibilities, previous therapy and outcomes, efficacy of potential treatments, timing and implementation of treatment, immediate adverse effects, and long-term risk of therapy, as well as the therapeutic skill of the physician in managing the follow-up care, must all be considered.

We can guard against making mistakes by changing the culture of psychiatric practice. Instead of focusing on medication, in-depth comprehensive assessments might be more beneficial. The patient-physician discussion can be oriented so that the patient understands the need for a thorough evaluation, the results of which will guide therapeutic recommendations.


Given the limitations of some of our current treatments and the opportunities for new directions, it is imperative that we expand our therapeutic skills to include new treatment models. The 

 and new, innovative services in Canada provide a unique opportunity to change direction and influence care in a positive way.

On January 1, 2014, the Patient Protection and Affordable Care Act went into effect, dramatically expanding coverage for psychiatry and behavioral health.

 No longer are health plans allowed to limit psychiatric care, and preexisting conditions cannot be a barrier to coverage. In addition, depression screening for all children and adults is available with no copayments, regardless of the type of insurance. The Affordable Care Act provides for obesity screening in adults as well as substance abuse and nicotine dependence screening for adults and adolescents. Prevention and disease management with measured health improvements is the focus of new health care models.

Up to now, behavioral health care has been provided by psychologists, social workers, and counselors working in primary care settings, which excluded psychiatrists. By being an integral part of the collaborative care team, psychiatrists are now in the position to lead the development and management of behavioral health care initiatives to address problems quickly, smoothly, and effectively. The Affordable Care Act makes this a clear priority, with financial incentives for those able to demonstrate results. Having psychiatrist involvement creates a new dimension and expands the ability to provide care.

PCPs see the majority of psychiatric patients. With the support of a psychiatrist, the PCP can decrease the use of potentially harmful medications when alternative treatments would be more appropriate. Psychiatrists can also assist PCPs in identifying the complex patient for referral. PCPs, with the support of psychiatrists, would also be expected to have basic skills in mental health education, cognitive-behavioral therapies, and safe medication management.

When new models of care are developed, it will be important that methods for intake and referral are seamless, with easy handoff. Patients can have multiple entries into a system through primary care, midlevel providers, and behavioral health workers, with easy referral to clinicians who have more training and experience. Certain patients with a single or uncomplicated diagnosis will likely continue to be managed by the PCP, midlevel provider, or behavioral health provider. Psychiatrists and PhD psychologists can provide supervision and oversight of care. More complex cases can be referred directly to senior psychiatric staff.

More than 60% of patients with MDD have comorbid medical conditions, such as hypertension, congestive heart failure, chronic back pain, diabetes, and arthritis, and would benefit from combined psychiatric and medical care. It would follow that referral patterns then should have more to do with the complexity of the patient’s condition than any specific treatment modality. Frequently in behavioral health settings, psychologists provide therapy and psychiatrists prescribe medications. But each discipline has areas of special expertise: PCPs are especially skilled in case identification and acute management; social workers are skilled in case management and certain therapies, such as eye movement desensitization and reprocessing; psychologists have special expertise in psychotherapy and neuropsychological testing; psychiatrists are skilled in evaluating complex patients, developing treatment plans, and providing psychopharmacology and psychotherapy. Complex patients would, out of necessity, have more time allotted for evaluation and treatment. Senior staff would be more involved in supporting those with less training, and the best trained and most experienced clinicians would constantly review and establish standards of care.

In this system, provision of care would vary in order to meet the needs of the patient rather than follow a specific treatment modality. It would also be important to create systems of care that are flexible and can use the ability of existing staff in the best possible way.

In collaborative integrated care, all clinicians could be involved in health coaching and basic cognitive-behavioral strategies-the licensed social worker and the psychiatrist might both do eye movement desensitization and reprocessing. A licensed independent social worker might work with a less complex patient while the psychiatrist provides eye movement desensitization and reprocessing for patients with comorbid disorders, eg, bipolar disorder and PTSD. This does not exclude the social worker from providing care for victims of sexual abuse or collaborating with the psychiatrist on complicated patients.

, psychiatric practice would be dynamic and challenging. Psychiatrists would take the lead and would have multiple responsibilities, such as providing oversight and clinical supervision, evaluating complex patients, developing comprehensive treatment plans, providing medication management and psychotherapies for complex patients, directing treatment teams, doing telepsychiatry, and planning patients’ discharges. Psychiatrists would also need to lead the team in providing 

, evaluation, and care: minorities have greater difficulties in accessing care,

 and the aging population requires the same attention and oversight.

The cost factors associated with psychiatric care are often a concern. Psychiatrists and other health care professionals would also need to ensure that optimum treatment is provided at the lowest cost possible.


It is time that psychiatry moves away from its present focus on medications and takes a new direction that uses other modalities of care-evidence-based psychotherapies. To fail to do so will lead to less effective treatment, and we will fall short in our ability to provide care for our patients. Expanding our therapeutic range for those with serious psychiatric disability within the bounds of honesty and transparency and within the context of research will lead to new treatments. As we discover more about those who achieve full remission, we can direct our research and treatment toward the goals of prevention and cure.

 We can set our sights on having a healthy, productive population with much reduced pain and suffering. The support from the Affordable Care Act for the new paradigm in the US and innovative programs in Canada can be a major impetus for moving in the right direction.

Dr Neidhardt was the Clinical Director for Northern Navajo Counseling Center in New Mexico with the Indian Health Service. He is in private practice in Santa Fe, New Mexico. He is board certified in psychiatry and integrative holistic medicine. 

Dr Ortiz is a former Professor at the University of New Mexico School of Medicine, has worked as a VA psychiatrist, and is currently a consulting psychiatrist in substance abuse programs, cultural psychiatry, and managed care in Albuquerque, New Mexico.  She is board certified in psychiatry, addiction psychiatry, and geriatric psychiatry. 

Dr Wright is Professor in the Departments of Anesthesiology, Pharmacology, and Therapeutics and Medicine at the University of British Columbia in Vancouver, BC. He is also the Co-Managing Director of the Therapeutics Initiative and Coordinating Editor of the Cochrane Hypertension Review Group. He is board certified in internal medicine and a practicing clinical pharmacologist.

Dr Roessel has spent most of her career working as one of the few Navajo psychiatrists in the Indian Health Service and consults to the First Nations Community Health Source in Albuquerque, New Mexico. She is in private practice in Santa Fe, New Mexico and is board certified in Psychiatry.

The authors report no conflicts of interest concerning the subject matter of this article.

1. Bradley R, Greene J, Russ E, et al. A multidimensional meta-analysis of psychotherapy for PTSD [published corrections appear in 

. 2005;162:214-227.
2. Seidler GH, Wagner FE. Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. 

. 2006;36:1515-1522.
3. Segal ZV, Williams JMG, Teasdale JD. 

Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse

. New York: The Guilford Press; 2002.
4. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders; a meta-analysis. 

. 2004;61:1208-1216.
5. Trivedi, MH, Rush AJ, Wisniewski SR, et al; STAR*D Study Team. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. 

. 2006;163:28-40.
6. Levine SZ, Rabinowitz J, Ascher-Svanum H, et al. Extent of attaining and maintaining symptom remission by antipsychotic medication in the treatment of chronic schizophrenia: evidence for the CATIE study. 

. 2011;133:42-46.
7. Smith G, Jongeling B, Hartmann P, et al. 

Raine ADHD Study Report: Long-Term Outcomes Associated With Stimulant Medication in the Treatment of ADHD in Children.

 Government of Western Australia, Department of Health, 2010. http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf. Accessed December 18, 2013.
8. Molina BS, Hinshaw SP, Swanson JM, et al. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. 

. 2009;48:484-500.
9. Kripke DF, Langer RD, Kline LE. Hypnotics’ association with mortality or cancer: a matched cohort study. 

. 2012;2:e000850.
10. 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. 

. 2013;70:913-920.
11. Burgess S, Geddes J, Hawton K, et al. Lithium for maintenance treatment of mood disorders. 

 2001:CD003013.
12. McMartin SE, Jacka FN, Colman I. The association between fruit and vegetable consumption and mental health disorders: evidence from five waves of a national survey of Canadians. 

 2013;56:225-230.
13. Rienks J, Dobson AJ, Mishra GD. Mediterranean dietary pattern and prevalence and incidence of depressive symptoms in mid-aged women: results from a large community-based prospective study.

. Patient Protection and Affordable Care Act: program integrity: exchange, premium stabilization programs, and market standards; amendments to the HHS notice of benefit and payment parameters for 2014. Final rule. 

. 2013;78:65045-65105.
15. US Department of Health and Human Services. 

Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of the Surgeon General.

 Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001.
16. McGrath CL, Kelley ME, Holtzheimer PE, et al. Toward a neuroimaging treatment selection biomarker for major depressive disorder. 

In order to make positive changes in the field of psychiatry, it is important to appreciate and understand the current challenges and significant limitations of the present approach to psychiatric therapy.

Mary Roessel, MD

Articles

Next Steps

Recovering Ancient Knowledge for the Good of the Earth

New Directions in Psychiatry