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Susan J. Noonan, MD, MPH shares strategies to assist patients in overcoming their fears about the COVID-19 pandemic.

To see the previous video on reentry anxiety, watch 

Reentry Anxiety: The Challenge of Returning to "Normal"

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

mental health and wellness virtual coaching practice, opening in July 2021, known as Noonan Wellness Coaching,and can be confidentially reached through her website at 

What are some ways to overcome anxieties about returning to "normal"?


Tackling Reentry Anxiety: Strategies for Coping

, Hannah Simon, MD, introduces a new series on teen and tween mental health. Her first guest is Andrew Chen, MD, MS, the chief medical officer for USA Nordic, the national leadership organization for Nordic Combined and Ski Jumping in the United States. They discuss the importance of mental wellbeing for peak athletic performance, the programs available for Olympic athletes, and how health care providers can help students succeed—in everything from the big game to the big test.

- Dr Chen’s path from medical school to the Olympic Games

- Simone Biles and fighting the stigma surrounding mental illness

- The mental health challenges facing school-aged children during the pandemic

- The importance of diet and nutrition for athletic performance and mental wellbeing

- 5 personality attributes that Olympians share (and what psychiatrists can learn from them)

is a child and adolescent psychiatry fellow at New York-Presbyterian Hospital.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Caring for Teens and Tweens podcast with experts in the field of psychiatry.

What can Olympians teach mental health professionals about caring for student athletes—and others too? 

5 Personality Traits of Olympic Athletes

Tales From the Clinic: The Art of Psychiatry,

 we cover an intriguing case of dual substance use super-imposed on mood, anxiety, and trauma clinical picture. A significant challenge for this group of patients is the need for patient, methodical, consistent care to unravel the complex multifaceted triggers and perpetuating factors for continued maladaptive behaviors. The case description spans years of treatment and, while the details may seem sensational, they reflect the reality of what the addiction treatment clinic team encounters. In addition, there is much difficulty in hearing and processing patient accounts of trauma, which could lead to physician burnout.

“Ms Martin” is a 45-year-old female with bipolar disorder, generalized anxiety disorder, and suspected borderline personality disorder. She was transferred to the substance use disorders clinic by another psychiatrist after a diagnosis of opioid use disorder was obvious. At the time of her transfer, she was involved in prostitution to finance her roughly 25 tablets of acetaminophen and hydrocodone daily. Her opioid use disorder history had a protracted course, with her first exposure to prescription opioids at the age of 16 following a significant injury requiring surgical intervention. Her longest lifetime period of sobriety was 2 years.

Her immediate environment was not conducive to recovery, as she lived in a trailer with a male roommate who had mutual acquaintances that provided pain pills. In addition, Ms Martin engaged in sexual activity with the roommate in exchange for opioids. As time progressed, the relationship became physically abusive; she left after her roommate tried to hit her with a vacuum cleaner when she “didn’t do a good job cleaning the trailer.” At the time, she had been in treatment for 1 year, was started in medication-assisted therapy (MAT), and had been prescribed buprenorphine. She moved into an apartment with her mother, which greatly reduced access to opioids. She responded very well to MAT, with an absence of significant relapses as evidenced by the drug screenings during her monthly visits.

Three years into treatment, Ms Martin met a new boyfriend. Her urine drug screen (UDS) resulted positive for amphetamine. He provided her with substances that boosted her energy and aided in weight loss. She was not fully aware of what she was taking, but she thought it might have been amphetamine since it came in a “large jar with many capsules.” Testing verified the presence of methamphetamine.

These results were shared with Ms Martin, to her genuine surprise, and she expressed earnest motivation to stop methamphetamine use. Unfortunately, over the next year, she eventually met criteria for stimulant (methamphetamine) use disorder. This paralleled toxic developments in her relationship. She described a continued strong sexual attachment to her partner, and she remained intimate with him despite knowledge that he was simultaneously sexually active with her mother. She later bashfully admitted engaging in group intercourse with her partner and mother. During intercourse she described her partner’s derogatory and sadistic tendencies, which she felt she “deserved.”

Eventually, she developed disgust toward him. This resulted in an internal conflict because while she described feeling revolted by him, she simultaneously experienced severe loneliness and feelings of abandonment when he did not give her attention. This fueled further methamphetamine use as she wanted to be “skinny and pretty.”

The ongoing sexual relationship between her partner and mother resulted in significant tension within the apartment they all shared. On multiple occasions, Ms Martin described anxiety that her partner and mother were colluding against her. Methamphetamine use may have intensified these feelings. Although at times she expressed a desire to leave, she felt she had nowhere to go. Her partner contributed to paying bills, which further complicated her situation.

For the next year, Ms Martin continued to express significant ambivalence about her relationship. She recognized how the situation placed a strain on her relationship with her mother, yet she simultaneously feared the rejection, abandonment, and loneliness that would result from a breakup. She described symptoms of anxiety and sadness when away from her partner, and he was using methamphetamine pills as a tool to control her. She compared her “love-hate” relationship with her significant other with that of her relationship with the methamphetamine pills.

In addition to work in building Ms Martin’s feelings of self-worth and autonomy, a motivational interviewing style was utilized to help her resolve some of her ambivalence toward the relationship. Although she voiced much more change talk to end the relationship, compared to sustain talk, she had difficulty committing to ending the relationship.

Due to the alarming rate of opioid overdoses secondary to fentanyl, clinicians and those struggling with substance use are becoming aware that the product purchased is not always as marketed. Anecdotal reports of increasing concomitant opioid and amphetamine use abound, but the condition is not well understood, nor systematically studied. In the case of this patient, confirmatory test showed methamphetamine, whereas she believed she was getting amphetamine or methylphenidate; she may have inadvertently gained access to a supply of methamphetamine.

Currently, there are no US Food and Drug Administration-approved treatments for methamphetamine use disorder. Some studies suggest the use of bupropion, naltrexone, and mirtazapine may have some limited efficacy in 

 In addition to treating Ms Martin’s SUD, the team addressed co-occurring mood and anxiety symptoms (she had witnessed her brother injured in a car accident). Her initial regimen included duloxetine and aripiprazole for depression, anxiety, and mood stabilization. Bupropion was not tried due to her concern of its risk of exacerbating her anxiety, and she declined mirtazapine due to its risk of weight gain because she already struggled with her body image. After Ms Martin expressed concerns that aripiprazole may be contributing to her weight gain, she was switched to cariprazine with the perceived potential benefit of weight-neutrality, since a desire for weight loss was a contributing factor to continued methamphetamine use. Another potential benefit of cariprazine includes preliminary interest in the D3 receptor affecting addictive behaviors.

Methylphenidate and lisdexamfetamine were other pharmacological therapies considered for treatment, given that Ms Martin has shown good response to replacement therapy such as buprenorphine. However, agonist substitution, while an excellent harm reduction approach, still faces stigma and resistance in clinical practice, especially for stimulant use.

According to the Centers for Disease Control, 40.4% of adults using methamphetamine within the last year also misused prescription opioids, and 16.9% used heroin between 2015 and 2018. In the United States there has been an increase in overdose deaths and hospital admissions involving 

 After limited availability of ephedrine and pseudoephedrine due to regulations, synthesis returned partially back to using phenyl-2-propanone (P2P).

 Due to increased purity and potency, there is concern that the P2P formulation may be contributing to addiction.

 This is something to keep in mind when treating a patient diagnosed with both opioid and stimulant use disorders. Unfortunately, there is no guideline as to whether MAT should be discontinued if a co-occurring substance use is still ongoing.

Ms Martin maintained abstinence from opioids while on MAT, but continued to use methamphetamine pills. The treatment team wondered if she was truly benefiting from the current level of care, and considered tapering off buprenorphine and referring her to a residential treatment program or a methadone clinic. However, Ms Martin did not have the financial resources for the latter and, in regards to the former, expressed anxiety and fear about being separated from her dog as well as the feeling of “being locked up.” Thus, her treatment team sought to maximize psychosocial support and psychotherapy interventions, but she had stopped going to group therapy and declined virtual therapy sessions.

With continued work, despite ongoing significant trauma, interpersonal conflict, financial instability, and continued methamphetamine use, Ms Martin increased engagement in treatment and is adherent with all medication management visits. The treatment team ultimately decided not to taper off the buprenorphine, given her gradual progress toward treatment goals was a product of a harm-reduction approach. She could have benefited from inpatient rehabilitation. However, reluctance to go into rehabilitation is common in patients with SUD. Additionally, most states do not allow involuntary inpatient SUD treatment as they do for involuntary psychiatric care, so patients have to suffer legal repercussion to be forced to attend court-ordered rehabilitation. Finally, many residential treatment programs may not be able to accommodate patients on MAT, as some are not yet comfortable with a harm-reduction approach or medical model of addictions treatment.

This case highlights several clinical and psychotherapeutic challenges that may arise in the treatment of substance use disorders. First, it is important to look for the presence of significant trauma in a patient with several barriers to care preventing access to psychotherapy, as there is a known link between a history of trauma and the development of 

 In this case, Ms Martin was a victim of physical, emotional, and sexual abuse. Unfortunately, there are limited standardized or manualized approaches to addressing trauma in patients with substance use disorders. When trauma informed therapy is available, access is often limited.

Similarly, another significant factor contributing to Ms Martin’s ambivalence about leaving the relationship was the codependency that existed with her partner.

Medication management visits typical to community psychiatry practice are likely not of sufficient length to address complex issues involving psychopharmacology and psychotherapy. Although the COVID-19 pandemic has accelerated the development of telepsychiatry, many patients do not have the technological means to make these visits and may not have private and safe living spaces where they can share sensitive information.

Additionally, drug use is perpetuated by perceived benefits, and cessation of use does not happen unless the patient appreciates the negative impact of substance use on their lives. When Ms Martin finally understood she was taking methamphetamine, it created an opportunity to see its use as a problem instead of an agent for cognitive enhancement/weight loss.

Methamphetamine is commonly used to improve sexual function. In fact, 

 has described methamphetamine as increasing sexual desire, pleasure, reducing the refractory period between intercourse, exacerbating impulsiveness, and impacting behavioral inhibition.

 In this case, it would be worth further exploring that idea, as the patient’s partner was supplying methamphetamine and requesting particular sexual demands.

A major challenge in the field continues to be the lack of available effective pharmacologic treatments for stimulant use disorders. Contingency management in combination with community reinforcement is a proven effective behavioral treatment for stimulant use disorders, as confirmed by 

 However, there are considerable barriers to implementing contingency management at this time, including public stigma and limited Medicaid support.

Lastly, in the context of treatment, it is often easy to feel patients are to blame for maladaptive, promiscuous, or risky behaviors. Countertransference feelings or bias may hinder patients getting expanded treatment options, especially if they display anger and hostility upon exploration of sensitive topics in session.

However, despite significant barriers to care, the presence of trauma, and ongoing struggles with stimulant use, patients demonstrate resilience and often continue to express desire for full recovery. Cognitive-behavioral therapy, relapse prevention, mindfulness, and psychodynamic therapies are all useful in treatment, but the level of complexity of patients with SUD often means a prolonged course of treatment with multiple modalities needed.

is a PGY-4 general psychiatry resident in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. He plans to pursue a fellowship in Addiction Psychiatry after graduation.

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. 

 is associate professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, and Ben Taub Adult Outpatient Services director, medical director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis. She also serves on

1. Colfax GN, Santos GM, Das M, et al Mirtazapine to reduce methamphetamine use: a randomized controlled trial. 

2. Elkashef AM, Rawson RA, Anderson AL, et al. Bupropion for the treatment of methamphetamine dependence. 

3. Trivedi MH, Walker R, Ling W, et al. Bupropion and naltrexone in methamphetamine use disorder. 

4. Jones CM, Underwood N, Compton W. Increases in methamphetamine use among heroin treatment admissions in the United States, 2008-2017. 

5. Maxwell JC, Brecht M-L. Methamphetamine: Here we go again? 

6. Dolatshahi B, Farhoudian A, Falahatdoost M, et al. A qualitative study of the relationship between methamphetamine abuse and sexual dysfunction in male substance abusers. 

7. Wiechelt SA, Straussner SLA. Introduction to the special issue: Examining the relationship between trauma and addiction. 

8. Colfax G, Shoptaw S. The methamphetamine epidemic: Implications for HIV prevention and treatment. 

9. De Crescenzo F, Ciabattini M, D’Alò GL, et al. Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. 

10. McMahan VM, Kingston S, Newman A, et al. Interest in reducing methamphetamine and opioid use among syringe services program participants in Washington State. 

A patient presents with multiple substance use disorders super-imposed on mood and anxiety disorders. Where does a clinician even begin?

I Had to Use

For many young patients (and their parents) the back-to-school season is an anxious time. How will they navigate their new classes? Will they get along with their teachers? Will they make friends? Their active imaginations can invent a hundred scary scenarios.

But what if their brilliant imaginations could help them build resilience instead? In this Mental Health Minute, Victoria Harris, DPsych, MA, offers practical tips and techniques to help children overcome their fears through the power of their creativity.

is a Humanistic & Integrative Psychotherapist and Supervisor in private practice who specializes in using creative techniques. She has trained in child psychotherapy and play therapy and researched the use of creative techniques in psychotherapy at Dublin City University. she helped develop a well-being school programme for 3rd & 4th class in Ireland for the charity 

 uses metaphor to help children navigate anxiety and loss will be released on October 5th, 2021. Dr. Harris believes strongly in early intervention and using creativity as a tool for healing.

How do you prepare patients for the back-to-school season? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

These imaginative exercises can help clinicians establish a strong therapeutic alliance with nervous youngsters. 

Looking for a Way to Beat Back-to-School Anxiety? Maybe It’s Time to Get Creative

As the need grows for equitable, accessible, and affordable mental health treatment, digital therapeutics—app-based treatments—show promise for filling these gaps, particularly to target anxiety. The high prevalence of anxiety disorders “vastly exceeds the capacities of mental health services” to 

Anxiety has risen since the beginning of the COVID-19 pandemic. The US Census Bureau reported that adults were 3 times more likely to screen positive for anxiety disorders in 2020 compared with 2019 (31% vs 8%). A cross-sectional 

of individuals conducted in China February 2020 found the prevalence of generalized anxiety disorder (GAD) to be 35.1%; a meta-analysis found an average anxiety prevalence of 32% during the pandemic (17 studies, n = 63,439).

 A study of patients diagnosed with COVID-19 between January and August 2020 (n = 62,000+) found that 1 in 5 patients with no psychiatric history received a new mental health diagnosis, with the greatest health risk being for anxiety disorders.

Digital therapeutics can be designed to specifically target a behavioral or psychological mechanism of action, and they can be developed with user-centered design principles to maximize engagement. However, to date, very few digital therapeutics have been tested for efficacy, and even fewer have been studied regarding mechanism of action. There seem to be 2 categories of digital therapeutics emerging: those that are commercially developed with little supporting evidence or plans for evaluation and those with academic or government backing (and often not easily available to consumers).

 The former has the advantage of maximizing curb appeal: Resources can be devoted toward developing engaging user experiences using the latest design techniques, and companies can push a digital therapeutic to market rapidly. Scientists have developed evidence-based digital therapeutics, yet few are publicly available. They appear more slowly than their commercial counterparts, and those that do appear usually fail to attract users and user engagement.

 However, both face the same fate: No matter how shiny an app is, it still takes time to run rigorous clinical trials to determine efficacy (and mechanism).

John Torous, MD, Digital Section Editor for 

 and chair of the American Psychiatric Association’s Smartphone App Evaluation Task Force, put it bluntly when interviewed for an article on digital therapeutics in Nature: “Right now it almost feels like the Wild West of health care.”

How can the busy health care clinician keep up-to-date on the latest trends, determine which digital therapeutics are evidence based, and give informed answers when patients ask which apps to use? Is there enough evidence for prescribers to pull out their proverbial digital prescription pad to recommend an app-based treatment for anxiety?

After considering the recent literature, there are a few questions clinicians should consider.

Why Should There Be an Effect? What Mechanism Is Being Targeted?

A good place to start is to consider if a digital therapeutic is mechanistically based. Although many apps assert that they are scientifically based, very few live up to this claim. The National Institutes of Health established a 

 called the Science of Behavior Change (SOBC) to focus on mechanisms of change in behavioral interventions as a way to both strengthen intervention development and “increase rigor, transparency, and dissemination of common terminology, methods, and measures.”

 The basic idea behind SOBC is to measure if a behavioral intervention engages a hypothesized mechanism of change and if engaging that target leads to change in a health outcome. If this approach sounds similar to that taken for the development of any new drug, it should, because it is. It was modeled after the experimental medicine approach. However, a significant research-practice gap exists in the digital mental health field, especially in the field of anxiety interventions.

Findings of a recent study looking at the frequency of evidence-based treatment elements in apps for anxiety showed that the most commonly included elements were psychoeducation (53%), relaxation (47%), meditation (41%), and mindfulness (29%) (

 Yet, the inclusion of an element does not automatically translate to targeting a specific mechanism or therapeutic benefit. Another recent review found that 67% of apps for anxiety lacked involvement of any health professional in their development, and just 4% had been empirically evaluated.

This unfortunate lack of focus on mechanism is not due to an absence of information on how anxiety can develop and be perpetuated. For example, decades-old research has suggested potential mechanisms of action, such as targeting worry-driven negative reinforcement, yet 

 have these been incorporated into digital therapeutic devopment.

With apps that can reach thousands, and even millions, of potential patients, it is much easier to collect data from a convenience sample, look for reductions in some type of scale, and then claim it to be an evidence-based treatment for anxiety. However, there is a world of difference between someone who is mildly anxious (after all, who is not these days?), and someone whose anxiety is severe enough to land them firmly in the realm of needing treatment for a DSM-diagnosed anxiety disorder. For example, a 

 of randomized controlled trials of mindfulness apps reported significant effect sizes for reductions in anxiety, but every study recruited individuals from app users and the general population and specific nonclinical groups (largely students and employees).

 Of these, only a single study included individuals with mild to moderate anxiety using the General Anxiety Disorder-7 (GAD-7) cutoff of 14 to exclude individuals who reported severe anxiety (GAD-7: 5-9, mild; 10-14, moderate; 15+, severe anxiety).

 of internet-based cognitive behavioral therapy (iCBT) used GAD-7 scores of ≥ 8 as a minimum cutoff to recruit individuals with mild to moderate symptoms of anxiety, individuals in the United Kingdom’s National Health System (NHS) and “who may be eligible and require iCBT” as part of the Improving Access to Psychological Therapies (IAPT) program.

 Additionally, 2 studies of app-based mindfulness training for anxiety (Unwinding Anxiety) have used GAD-7 scores of ≥ 10 as minimum cutoff for inclusion of anxious physicians and individuals with GAD, respectively.

 Taken together, these results suggest that the majority of studies are drawing convenience samples from nonclinical populations, and that can lead to problematic inferences on the efficacy and utility of digital therapeutics in individuals with moderate to severe anxiety—those that would be most likely to seek or be referred to treatment—unless they have been specifically studied in these populations.

What Is the Evidence? Is There a Clinically Relevant Reduction in Symptoms?

Popularity does not equal evidence for efficacy. A number of app-based programs have put a primary focus on increasing their user base rather than developing digital therapeutics for anxiety. Although there is nothing inherently wrong with this approach—it is just a different focus—seeing a lot of individuals use an app can lead to a false sense of efficacy. Most studies to date are small pilot studies, often run by the app developers rather than by independent researchers, and the results have yet to be replicated. Additionally, many studies are run relative to wait-list control groups. Although this is better than no control group, it does not assess basic confounding components that are covered by a treatment as usual control group, such as receiving some type of treatment and expectancy effects (which, if performed well, will include the usual clinical care delivered by their therapist or doctor).

As previously mentioned, only a few published studies have examined digital therapeutics in individuals with moderate to severe anxiety: 1 in the general population (mainly recruited from users who were already signed up for the app Pacifica) with baseline GAD-7 scores of between 5 and 14; 1 (iCBT) in the UK’s NHS in individuals with baseline GAD-7 scores of ≥ 8; 1 (Unwinding Anxiety) in anxious physicians with baseline GAD-7 scores of ≥ 10; and 1 (Unwinding Anxiety) in individuals with GAD with baseline GAD-7 scores of ≥ 10.

In the first study, a randomized controlled trial that compared the Pacifica app to a wait-list control, only 35% of the app and 47% of wait-list participants completed the study. A composite anxiety score, using an average score of standardized GAD-7 and Depression and Anxiety Stress Scale-21 (anxiety component) scores, showed a statistically significant drop in both groups after 4 weeks (wait-list control, 0.23 composite point; Pacifica, 0.66 composite point), which was reported as statistically significantly different. In the second study, a randomized controlled trial of iCBT (Silvercloud) vs wait-list control, individuals in the iCBT group showed a statistically significant 35% reduction in GAD-7 scores at 8 weeks (baseline, 12.7; 8-week follow-up, 8.2) relative to a 15% reduction in the control group (baseline, 12.7; 8-week follow-up, 10.8). Retention was 82% and 76%, respectively.

In the third study, a single-arm trial of the Unwinding Anxiety app, anxious physicians demonstrated a statistically significant reduction in GAD-7 scores of 48% and 57% after 1 and 3 months, respectively (baseline, 11.5; 1-month, follow-up, 6.0; 3-month follow-up, 5.0). Retention was 60%. In the fourth randomized controlled trial looking at Unwinding Anxiety vs treatment as usual (TAU), individuals randomized to Unwinding Anxiety showed a statistically significant 67% reduction in GAD-7 scores (baseline, 12.0; 2-month follow-up, 3.0) relative to a 14% reduction in the TAU group at 2 months (baseline, 13.0; 2-month follow-up, 10.0). Retention was 88% for the Unwinding Anxiety group and 100% for the TAU group.

When prescribing a medication or suggesting that a patient try a behavioral treatment, we fall back on the ideals of the Hippocratic oath that we took at the beginning of medical school: First, do no harm. Although digital therapeutics do not carry the traditional adverse effect risk profile of a medication, it is important to approach information in a parallel manner: Ingesting information is not free of unintended consequences. For example, 

 for bipolar disorder found the presentation of information that could lead to harm (eg, encouraging individuals to drink liquor to help them sleep during manic episodes).

 Additionally, privacy is a concern, as apps can easily collect personal information ranging from symptoms to geolocation.

Digital therapeutics have the potential to live up to their promise: Mechanistic and evidence-based treatments that can be widely disseminated at low cost. To date, very few have demonstrated efficacy, and these studies would benefit from replication and extension of their findings. As clinicians consider recommending app-based treatments, it is important to stay abreast of emerging study results, and as they evaluate apps for their patients, they must keep those aforementioned important questions in mind (

is an associate professor of psychiatry at the Warren Alpert Medical School of Brown University, executive medical director of behavioral health at Sharecare Inc, and author of Unwinding Anxiety. Twitter: @judbrewer. He owns stock in, and serves as a paid consultant for, Sharecare Inc, the company that owns the Unwinding Anxiety app described in this article. The financial interest has been disclosed to and is being managed by his institution, Brown University, in accordance with its Conflict of Interest and Conflict of Commitment policies.

1. Firth J, Torous J, Carney R, et al. Digital technologies in the treatment of anxiety: recent innovations and future directions. 

2. Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. 

3. Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. 

4. Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. 

5. Bowland S, Hensley M, Johnson B, Fleming A. Consumer focus groups: a key to transforming behavioral health systems?

6. Anthes E. Mental health: there’s an app for that. 

7. Keller C, Ferrer RA, King RB, Collier E. Future directions of the National Institutes of Health Science of Behavior Change Program. 

8. Wasil AR, Venturo-Conerly KE, Shingleton RM, Weisz JR. A review of popular smartphone apps for depression and anxiety: assessing the inclusion of evidence-based content. 

9. Sucala M, Cuijpers P, Muench F, et al. Anxiety: there is an app for that. A systematic review of anxiety apps. 

10. Brewer JA. Why targeting entrenched habits can treat anxiety. 

 March 19, 2021. Accessed June 21, 2021. 

11. Brewer JA, Roy A, Deluty A, et al. Can mindfulness mechanistically target worry to improve sleep disturbances? Theory and study protocol for app-based anxiety program. 

Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind

13. Janes AC, Datko M, Roy A, et al. Clinical efficacy and psychological mechanisms of an app-based digital therapeutic for generalized anxiety disorder. Under review.

14. Gál É, Ştefan S, Cristea IA. The efficacy of mindfulness meditation apps in enhancing users’ well-being and mental health related outcomes: a meta-analysis of randomized controlled trials. 

15. Richards D, Enrique A, Eilert N, et al. A pragmatic randomized waitlist-controlled effectiveness and cost-effectiveness trial of digital interventions for depression and anxiety. 

16. Roy A, Druker S, Hoge EA, Brewer JA. Physician anxiety and burnout: symptom correlates and a prospective pilot study of app-delivered mindfulness training. 

17. Moberg C, Niles A, Beermann D. Guided self-help works: randomized waitlist controlled trial of Pacifica, a mobile app integrating cognitive behavioral therapy and mindfulness for stress, anxiety, and depression. 

18. Nicholas J, Larsen ME, Proudfoot J, Christensen H. Mobile apps for bipolar disorder: a systematic review of features and content quality. 

Key questions to consider when evaluating a digital therapeutic for anxiety. 

Anxiety Treatment at Your Fingertips

I am delighted to introduce this important supplement of 

™. In the context of the COVID-19 pandemic, telepsychiatry has passed its tipping point and now become a mainstream method of providing mental health services. In contrast, more complex solutions such as artificial intelligence, technology-enabled care, and smartphone applications are not yet mainstream.

However, the integration of digital technologies into psychiatric care has only just begun. Looking ahead, I believe that technology-enabled care will be the defining advancement of mental health services in this generation. I believe there are 3 key trends that have shaped how we got here and give us clues to what the future holds.

Rapid Erosion of Stigma and Surging Demand

The COVID-19 pandemic created a series of conditions that both increased the overall risk for mental illness and triggered specific episodes: uncertainty about life or death, bereavement of loved ones, chronic isolation, job loss, financial uncertainty, and loss of numerous life events (prom, graduation, weddings, etc). The result has been a rapid increase in anxiety, depression, and alcohol use, with a whopping 40% of Americans reporting at least 1 mental health condition, and more than 10% seriously considering 

At the same time, the pandemic circumstances have made it easier to talk about these experiences of depression and anxiety, in part, because they were understandable reactions to the various facets of a global crisis. On top of that, celebrities and other influencers have been speaking about their own mental health challenges, thereby normalizing the experience and providing hope for treatment.

For examples, 23-time Olympic gold medalist swimmer Michael Phelps, and singer-songwriter Demi Lovato have both shared their experiences as part of serving as marketing ambassadors for Talkspace. Similarly, tennis player Naomi Osaka, the highest-paid female athlete in the world, recently shared her experience with depression and anxiety in an Instagram post, explaining why she did not want to participate in postmatch conferences.

These are not isolated events, and they make a huge impression on individuals everywhere who have their own struggles with mental health. As a result, an increasing number of people are seeking treatment than ever before.

Great Influx of Private Investment in Mental Health

Observing the decline in stigma and rise in demand, investors have been pouring money into mental health. For instance, earlier this year I published a discussion on this topic after finding that venture capital investors dedicated a record breaking $637 million to 

 in 2019, which was a 23-fold increase from 2013.

 Estimates now suggest that venture capital 

 in 2020 and is poised to surpass $2 billion in 2021.

In addition to venture capital, private equity companies are also investing in mental health; they are focusing on consolidating addiction facilities, residential treatment centers, and outpatient mental health clinics. In June 2021, LifeStance Health, one of the nation’s largest providers of outpatient psychiatric services, joined the Nasdaq stock exchange in an initial public offering 

You may be wondering why private investment is relevant to technology. We know technologies provide opportunities for mental health treatments to be scaled up. For investors, technology is attractive, as it is the key to driving larger returns. As we see more and more investment in mental health from private investors, I expect to see a greater focus on digital technologies, ranging from the basics like appointment scheduling and messaging between patients and clinicians, to more advanced features like chatbots and do-it-yourself smartphone applications as initial or complementary treatments. For psychiatrists, these technologies will enable us to treat more patients and disseminate care more widely than ever before.

Toward a Post–COVID-19 Future: Hybrid Care

The big question is: How will we get from where we are now, which is a loose combination of telepsychiatry and traditional care, to this futuristic digitally enabled care model?

Like all sustainable innovation, I predict that technologies will advance incrementally, steadily marching toward the day when digitally enabled care will be the norm (

). Just as telepsychiatry is now a patient expectation, patients will also expect appointment rescheduling, billing, and documents (including signature) to be fully digital in the next 10 years. In addition, the ability to send asynchronous messages to the provider in a secure format will be common. Finally, as insurance companies play a role in how care is reimbursed and delivered, there will be a growing expectation that digital tools (ie, smartphone application modules for cognitive behavioral therapy) will help to reduce either the length or number of sessions needed for milder conditions and treatments.

The world is digitally powered, and our treatments will have to be digitally enabled if we are going to meet patients where they are: on their smartphones. Demand is surging, stigma is declining, and private investors will continue to push technologies that scale up our treatments. The field of psychiatry is poised to take advantage of this brave new world to better care for patients. I have never been as excited to be a psychiatrist as I am today. Happy reading—our future awaits!

is the Chief Innovation Officer at Columbia Psychiatry and assistant professor of psychiatry at Columbia University Irving Medical Center. He is an advisor and holds equity in the following mental health startups: Two Chairs, Mantra Health, Tempest, and GroupWell. These companies are not referenced in this article.

1. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. 

2. Shah RN, Berry OO. The rise of venture capital investing in mental health. 

3. Thorne J. Driven by pandemic demand, mental health startups surpass 2019 funding. 

. October 14, 2020. Accessed June 29, 2021. 

4. Landi H. Mental health provider LifeStance Health valued at more than $7B as stock jumps following IPO. 

. June 15, 2021. Accessed June 29, 2021. 

What will psychiatric practice look like in the year 2030? 

Technology-Enabled Care: The Future of Our Field

In the United States, the Centers for Disease Control and Prevention (CDC) 

that in 2019, 4.7% of adults aged 18 years or older reported regular feelings of depression, and 11.2% reported regular feelings of worry, nervousness, or anxiety.

 Forty percent of Americans with a 12-month history of severe mental disorders 

 Disorders were assessed by structured diagnostic interview using the World Health Organization’s World Mental Health Composite International Diagnostic following DSM-IV criteria. The analyzed disorders included mood (ie, major depressive disorder, dysthymia, or bipolar disorder type I or II), anxiety (ie, generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia), posttraumatic stress disorder, and substance use disorders (ie, alcohol or drug abuse or dependence). In lower- and middle-income countries, this figure can exceed 75%.

The ongoing COVID-19 pandemic has increased mental health care needs while simultaneously restricting access, with unknown long-term consequences. From August 2020 to February 2021, the CDC 

an increase in the proportion of adults reporting recent symptoms of anxiety or depression from 36.4% to 41.5%, with the fraction reporting unmet mental health care needs increasing from 9.2% to 11.7%.

 Among children and adolescents, the proportion of mental health–related 

visits for those aged 5 to 11 years and 12 to 17 years increased 24% and 31%, respectively, compared with 2019.

is a clinical research psychologist, an adjunct faculty member in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, and the founder and president of

is a practicing psychiatrist, an adjunct assistant professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, and vice president and medical director of

1. Norris T, Clark TC, Boersma P, Schiller JS. Technical notes for early release of selected estimates based on data from the National Health Interview Survey. National Center for Health Statistics. February 2021. Accessed June 25, 2021. 

2. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. 

3. Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of anxiety or depressive disorder and use of mental health care among adults during the COVID-19 pandemic – United States, August 2020-February 2021. 

4. Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental health–related emergency department visits among children aged <18 years during the COVID-19 pandemic – United States, January 1-October 17, 2020. 

What are the greatest unmet mental health needs in the United States today? Recent statistics from the Centers for Disease Control may hold the answers. 

Mental Health in America: A Growing Crisis

Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.

The psychiatric casualties of war may be inevitable, but the way the military responds to them is not. Since the 19th century, numerous books have been written on the history of war trauma, and they have included 

 Too often, however, the United States it seems like the military has failed to learn the lessons of the previous war. Veterans’ mental health has suffered in the process, resulting in a generational cycle of largely 

Why has the American military’s health care system refused to learn the fundamental lessons of wartime trauma, and how can the system be improved? Based on decades of research, writing, and our lived experiences as active-duty service members and mental health clinicians, we have taken up these questions in 

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 We offer concrete solutions that, if enacted, could propel the military as a lead social change agent in eliminating harmful mental health stigma and disparities.

. I can trace my interest in war trauma back to the second grade, when I was living on the Camp Pendleton Marine Base in Oceanside, California. It was 1968, the height of the Tet Offensive in Vietnam. My father was a career enlisted Marine, a combat veteran of the Korean war and currently serving in the Vietnam war.

I have vivid memories of a steady stream of classmates whose names were called over the loudspeaker and instructed to go to the nurse’s office to be met with what we could only assume was traumatic news. The visibly anguished teachers had us keep our heads down on our desks while the nervous students gathered their personal effects; they were met at the door by an entourage composed of the vice principal, school nurse, and the base chaplain. We never saw those classmates and friends again.

When I embarked on my enlisted Marine career in 1979, I witnessed firsthand the residual effects of trauma associated with military service during war and peacetime. As a young lance corporal, I was hospitalized with a surgically-repaired broken jaw, and I serendipitously read David S. Viscott, MD’s 

 It resonated with my childhood experiences and ignited my dream of becoming a military psychologist.

In 1989, I ended my enlisted career in pursuit of a doctorate degree in clinical psychology at the Pacific Graduate School of Psychology (now Palo Alto University). For my dissertation I interviewed hundreds of combat veterans from World War II, the Korean War, and the Vietnam War.

 In 1992, I fulfilled my dream by restarting a career as a Navy clinical psychologist in the aftermath of the Persian Gulf War.

In 2003, I was deployed as head of neuropsychiatry for Fleet Hospital Eight in Bremerton, Washington, in support of the Iraq War invasion. It was then that I was awakened to the military’s failed mental health policies. My naval officer career was cut short due to my assuming the role of 

 Much of this story is documented in Tom Donahue’s film, 

Perhaps the most pivotal experience occurred after President Bush prematurely proclaimed “mission accomplished.” Near the same time the military’s highest ranking psychiatrist visited our field hospital and presented the outcomes of an innovative combat stress screening and reconditioning program.

 The admiral fatefully pronounced, “This is very exceptional work; however, unfortunately, it will all be forgotten and will need to be rediscovered by the next generation.”

After my military retirement in 2009, I embarked on a new career at Antioch University Seattle’s Doctor of Psychology (PsyD) program and established the Institute of WarStress Injury, Recovery, and Social Justice. Its mission is to end the pattern of mental health neglect and stigma associated with crises within and outside of military circles. The opportunity to collaborate with someone as esteemed as Charles Figley, PhD, the institute’s board chair, has been instrumental in paving the way to fulfill these high-vaulted goals. 

 represents our collective efforts to share a written history in the hopes of ending the harmful consequences of neglecting war trauma lessons. In doing so, we hope the military will take a lead role in transforming mental health care in this country.

Writing this book with Mark was an education. I do not recall the first time I corresponded with Mark, but I had heard of him for some time. He was already a hero among those most connected to veterans’ rights. Coming from a military family, he believed in and loved America and its military so deeply yet he was willing to risk everything to help veterans get better health care.

We wrote this book to identify what has gone wrong and to share a blueprint for correcting the harms we uncovered.

A working model for eliminating stigma and transforming mental healthcare within the military.

Anxiety & Stress Disorders