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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.

Mark’s journey from enlisted Marine to naval officer had enabled him to become the strongest voice for systemic improvement in behavioral health within the military. The bedrock values that emerged from our study are vital to all fighting forces: trust, confidence, and collective effort—despite the fear and fog of war.

We knew there would need to be at least one significant book to address the relevant research. There was so much to report—so many stories of hope and then disappointment. The deeper we dove into the files, the more consistent the larger story became. Soldiers are taught to fight, and even kill, but their system of care does too little to prepare them for combat, and too little to help them reflect on their experiences afterward. Too often, they have no answer to reasonable questions, such as “how will I be treated if I am injured and need help?”

Our primary goal is first to convince our colleagues and fellow researchers that the number of psychological and psychiatric casualties are staggering, despite the fact that they rarely register on a measuring device beyond paper-and-pencil tests.

Every war cohort since World War I has described 10 fundamental lessons of war trauma; these lessons seem to be routinely ignored and then need to be rediscovered.

 These lessons include 1) the need to provide comprehensive mental health services including definitive treatment for traumatic stress injuries prior to discharge from the military; and 2) the need to eliminate mental health stigma and barriers to care.

Neglecting war trauma lessons perpetuates a preventable generational cycle of mental health crises.

To manage the military’s dilemma of fulfilling the 2 often competing missions of fighting and winning wars with providing health protection to its forces, the military has relied upon 10 strategies that prevent it from advancing war trauma lessons.

 For instance, the military’s 100-year-old frontline psychiatry doctrine is primarily aimed at reducing both personnel attrition and the cost of mental-health-related disability pensions. However, we argue that this doctrine is ultimately quite harmful to the well-being of veterans and their families.

War is not a pleasant thing, but we can learn from it. For instance, lessons from combat medicine have helped advance emergency medical and mental health care. By synthesizing the lessons learned from the mental health impacts of war trauma, we may find a working model to transform mental health care in general and eliminate related stigma.

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service.

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

1. Appel JW, Beebe GW. Preventive psychiatry; an epidemiologic approach.

2. Russell MC, Figley CR. Generational wartime behavioral health crises: part one of a preliminary analysis.

3. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: part two of a preliminary analysis.

6. Russell MC. Attentional focus and states-of-mind in post-traumatic stress disorder among

7. Zoroya G. Psychologist: Navy faces crisis. 

. January 17, 2007. Accessed July 14, 2021. 

8. Russell M. Mental health crisis in the Department of Defense: DoD Inspector General Hotline Investigation #98829 submitted by Commander Mark Russell, USN on 05JAN2006. Available upon request via Freedom of Information Act (FOIA) at Department of Defense; Office of Freedom of Information, 1155 Defense Pentagon; Washington, DC 20301-1155.

9. Russell M. The future of mental health care in the Department of Defense. Invited testimony before the Congressionally-mandated Department of Defense Task Force on Mental Health, on 19-20 October 2006, San Diego, CA.

Strangers at home: The Untold Story of American Military Mental Health

12. Russell M, Shoquist D, Chambers C. Effectively managing the psychological wounds of war. 

13. Glass AJ. Lessons learned. In: Glass AJ, Bernucci RJ, eds. 

Medical Department United States Army. Neuropsychiatry in World War II Volume I: Zone of Interior.

 Office of the Surgeon General, Department of the Army; 1966:735-759.

Between Flesh and Steel: A History of Military Medicine From the Middle Ages to the War in Afghanistan

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

Treating Psychiatric Combat Casualties

The last week of June 2021 was a momentous one.

After the cancellation of last year’s residency graduation, I was tasked with planning an event to celebrate both the 2020 graduates and those advancing in July. I had never planned an event like this before, especially during a global pandemic. I had no idea how much preparation and effort it would take—the room, food, decorations, tables, chairs, etc. To say it was a little daunting is an understatement.

And while I successfully planned for all the minutiae needed for the event, my wife pointed out a small detail that I had been avoiding as I finally neared the big day: I needed a haircut

The last time I had gone to my friendly local barber, it had been pretty awkward. The shop was full of frustrated, angry workers strained from closures and boasting that they had no intention of following any COVID-19 guidelines. I kept quiet and tried to be polite but was eventually asked what I did for a living. After sharing that I worked in leadership at a local hospital, the demeanor changed. Suddenly the man cutting my hair began to smile almost apologetically, gently touching my shoulder as I paid him and left.

This time, I did not know what to expect. Do I wear a mask? Do I try a new shop? Do I skip it altogether? The earlier experience was making me apprehensive. After talking to my wife, I decided I would go to the same barber. Entering the shop without a mask felt almost alien to me, and I must admit, it was slightly unsettling to sit with 15 or so others waiting on cuts.

I have learned that my experiences in the barbershop were in no way unique, and many of our patients and staff are dealing with similar situations on a daily basis. It is time to embrace the fact that reentry anxiety is affecting more individuals than ever before. This kind of anxiety is frequently seen in the severely isolated, the hypervigilant, and those confined to only certain places over 

 Doesn’t that describe almost all of us? Lockdowns and social isolation may have been necessary, but they are not something our brains are used to, nor can we easily flip a switch back to normal.

The data is there. According to the American Psychological Association, Americans are now experiencing the highest levels of stress since April 2020, with 

 reporting feeling at least one emotion associated with prolonged stress in the past 2 weeks (anxiety 47%, sadness 44%, and anger 39%).

 One study found that 13% of individuals screened positive for posttraumatic stress disorder, despite COVID-19 not fitting Criterion A. Thirteen percent felt they had difficulty with lockdown, 11% feared difficulty obtaining supplies, 10% had significant difficulty self-isolating, and 22% had 

And now I needed to plan a graduation for 2 cohorts of graduates, doubling the event’s normal prepandemic attendance. Graduation is supposed to be a time of celebration and togetherness, but as I am sitting here uneasy about just getting a haircut, I am wondering if it is really a good idea to do this event. This is supposed to be fun; why am I not looking forward to this?

We are supposed to be excited. We are supposed to feel good about doing more things. But reentry anxiety will not allow us to simply enjoy it.

Cognitively, it makes perfect sense: fear of contagion, feelings that the world has changed. I have even heard people joking that their social skills have atrophied, or they no longer know how to dress for various occasions.

What can we do about this? Like most solutions in the field, we need to understand the risk factors for those more likely to struggle with reentry. Look for patients with a history of mental illness, as well as those likely to have been stressed or dealing with trauma over the last year: front-line workers; people of color; parents; and children, teens, and young adults displaced from school.

The mechanism of action is a hard one, described by 

 When individuals repeatedly end a honeymoon phase only to be met with a new crisis, they then must recover from said crisis and adjust to the new situation. The hardest part is that individuals tend to suffer from these crises repeatedly, 

Although many consider reentry anxiety an anxiety disorder, it is really more of an adjustment disorder—especially when it is short term and related to a pandemic that forced us all to adjust. That being said, ruling out other causes for anxiety should be considered if symptoms persist.

But what do we do for these patients with this unique adjustment disorder? One of the first steps is diagnosis. The 

DSM’s description of adjustment disorder

 can guide providers in understanding the clinical symptoms and how to diagnose them appropriately.

Personally, my first step is the same as for all patients with anxiety—to help them give themselves permission to feel anxious. We get anxious—if we did not, we would fail to study for exams or forget to look both ways before crossing a street. Anxiety helps us make good choices in our day-to-day lives, as well as during rapidly changing times. It is important to permit feeling anxiety and to remind ourselves that everyone will deal with this differently. Comparing your feelings and coping skills to others is not productive. Just because certain individuals take longer to readjust, or their feelings are more intense, does not mean anything has gone wrong.

Of course, if patients’ symptoms persist or become disabling, it is important to offer help. Here are a few options that I recommend as appropriate:

. Cognitive behavioral therapy is the gold standard for anxiety disorders, and exposure therapy will likely help a lot. With the variety of options in obtaining it nowadays, it is easier to fit therapy into a busy schedule.

. Some research suggests that mindfulness practices can actually mimic exposure therapy by helping patients feel and desensitize troubling emotions and physical sensations.

. Gradual exposure to more challenging situations will likely begin to extinguish these symptoms. In addition, strong social support through family and friends is always beneficial.

. From a pharmacologic standpoint, I would hold off in mild cases. But for patients with disabling symptoms, a selective serotonin reuptake inhibitor might help them push through while undergoing therapy.

Looking back to my recent trip to the barbershop, I think it is important to acknowledge that many of us have experienced some trauma during this pandemic. There is no single method for getting back to normal. Equally important is that we seek to understand and embrace these feelings of trauma. Start with small outings at first, but start soon. Start with a haircut before you host a large party. Learn from my mistakes. Graduation was fun, but hosting over 100 guests indoors was indeed overwhelming.

Admittedly, a week later, I am more comfortable going outside of my bubble; however, I still feel more comfortable wearing a mask at the grocery store. We must all take steps that make us feel personally safe, but we should also push ourselves to get back to our lives.

is chair of Behavioral Health at Arrowhead Regional Medical Center. He also serves as medical director for the Behavioral Health Department at Arrowhead Regional Medical Center. In addition to San Bernardino, Dr. Seigler has practiced clinically in Riverside and across the West Coast as a Vituity

telepsychiatrist since 2017. He received his medical degree from the UCLA David Geffen School of Medicine and completed his postgraduate training at the UCLA/San Fernando Valley residency program. He has a passion for patients’ rights and returning stabilized patients back into the community from long-term placements and conservatorship.

1. Hyde J, Bolton R, Kim B, et al. "I've just never done that:" The influence of transitional anxiety on post-incarceration reentry and reintegration experiences among veterans. 

2. American Psychological Association. Post-inauguration stress survey: More than 8 in 10 Americans (84%) report feeling emotions associated with stress in the last two weeks. January 2021. Accessed July 27, 2021. https://www.apa.org/images/sia-january-emotions-infographic_tcm7-283972.jpg

3. Bridgland VME, Moeck EK, Green DM, et al. Why the COVID-19 pandemic is a traumatic stressor. 

4. Gullahorn JT, Gullahorn JE. An extension of the U-curve hypothesis. 

5. Purtill J. Anxious about going back to normal? It's called 'reverse culture shock'. Australian Broadcasting Company. May 7, 2020. Accessed July 20, 2021. 

6. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (US); 2016.

Why does the prospect of getting back to normal after the pandemic disturb some patients? And what can be done to overcome these fears?   

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