In a recent conference organized out of Prague and moved online, a presenter from the United Kingdom shared a list of concerns that seemed to go on forever of all that is frightening people these days. Foremost on his list were Covid19, what seem to many like authoritarian governmental measures to control its spread, uncertainty about the economy, and the questionable competence of world leaders in the face of a mounting global crisis. In the United States, these are compounded by unrest over police brutality against Black people forcing many to re-examine the legacy of 400 years of what historians call our “peculiar institution” of slavery. Author and clinician James Lake MD is an integrative psychiatrist who has witnessed the effects of this “perfect storm” close up. For Psychiatry Times, Lake authored a column on what he calls A Mental Health Pandemic: The Second Wave of COVID-19. He urged a re-think of typical mental health responses to include integrative solutions in his “Call for a National Strategy.” I reached Lake to explore what has steered his vision to make such dire predictions, and to explore how integrative methods might best figure into solutions.

Lake founded and from 2002-2010 helped lead the integrative psychiatry caucus of the American Psychiatric Association.  He is presently a visiting assistant professor of medicine in the Department of Psychiatry at the University of Arizona School of Medicine and was previously on clinical faculty in the department of psychiatry and behavioral science at Stanford. Textbooks he has authored or co-edited include Chinese Medical Psychiatry: A Clinical Manual,  Textbook of Integrative Mental Health Care,  Complementary and Alternative Treatments in Mental Health Care and Integrative Mental Health Care: A Therapist’s Handbook and An Integrative Paradigm for Mental Care: Ideas and Methods Shaping the Future. Lake has also published a series of 10 e-books on alternative and integrative approaches in mental health care for patients and the general public. His clinical work has included stints at a VA clinic and at Kaiser Northern California. He presently works virtually at a community health center providing care to low income and Medicaid patients on the Central California coast.

Integrator: Anyone who has a pulse will know that fear and anxiety are up. And anyone following the news will know we are already seeing mental health issues. But “pandemic”?

Lake:  Millions of people are chronically exposed to the issues surrounding COVID-19. The stress level is severe. Many are afraid of becoming sick or dying. Many have lost loved ones. Everyone is wondering who will be next? A society that is already filled with lonely people has seen loneliness exacerbated by enforced social distancing. If COVID-19 hasn’t yet touched everyone directly, the economic stresses related to the shutdown most likely have – or at least have touched many around them. There is a widely shared feeling of loss of control in all of this. And there is no sense of when or whether things will get better. The incidence of anxiety, depression, suicide, as well as domestic violence and substance abuse among people who are being directed to stay home indefinitely, in many cases in the absence of meaningful social contact, are all on the rise. This could go on for years. It’s a perfect storm. We need to approach this situation as a second wave of Covid19, a mental health pandemic in the making. We need to come up with a proactive coordinated strategy without delay – or things could get much worse. That’s why I called for a national strategy –one in which we address the limitations of the current model of care and available conventional treatments. We need to come up with a model of care and treatments that are more effective while also being cost-effective. In my view these innovations should include collaborative and increased use of evidence-based CAM and integrative approaches.

Integrator: I am curious, in your practice, are there new characteristics you are seeing in people during COVID? On the physical health side, those working with COVID-19 will say it’s “not like any other flu.” Are there ways that this situation is clearly worse than mental health challenges that have faced people in this country and others for years?

Lake: My take on it is that there is a collective social weariness weighing down on people, weighing down on society. Our psyches and spirits are weary. There’s uncertainty about the future, anxiety about jobs, paying the mortgage, paying rent. There’s widespread loss of locus of control that I’ve written about in another column. It’s a very heavy weariness that is being exacerbated in the U.S. by divisive political discourse and racial tensions. And pretty much everyone is being affected. Even people with good jobs don’t know what may happen, don’t know what will happen with their property values and their stock portfolios, what course their lives will take. Will hunger and the increasing number of homeless become a  humanitarian crisis? I believe the greatest concerns and the worst dangers are among those who are already dispossessed, those who have the least amount to lose. As I said in the Psychiatric Times column, if left untreated, the psychiatric sequelae associated with the pandemic will probably have serious long-term social and financial consequences for all areas of human life, including personal relationships, family dynamics, academic performance, and work productivity. It’s why we need to make a plan now – to not stumble into this, but take it on in a way that is highly organized focusing on the most urgent priorities.

Response from the American Psychiatric Association?

Integrator: Have you had received any feedback on the column from the APA or elsewhere? Is this idea of a mental health pandemic picking up?

Lake: I haven’t heard from the APA or other organizations. The column was published only last week. But I’ve seen op-ed pieces in places like the New York Times and Politico that have presented a consistently bleak view of the emerging mental health picture. There is also evidence of more domestic violence which seems to be linked to the pandemic. I’ve seen similar comments out of the United Kingdom and Germany as well as China. But I haven’t read articles that are labeling the mental health consequences of Covid19 and the surrounding economic crisis a pandemic. We need to be tracking the data to get a sense of the magnitude of the problem. But it’s clearly enormous.  If we don’t take a proactive stance I am concerned that we may end up doing too little too late. We’ve seen the enormous cost in lives lost that resulted from being late in developing a coherent national strategy and under-estimating COVID-19’s impact on health. We need to get ahead of this.

Integrator: As you’ve commented in your writing, the American Psychiatric Association is a conservative organization that emphasizes conventional pharmaceutical approaches. Does it occur to you that for them, a national strategy on a mental health phase of a pandemic might be as reductive and limited as is the present reductive focus on prescription antivirals and vaccines are on the physical side?  Might major investment devolve into a global campaign to create a kind of happiness producing Orwellian “soma” of Brave New World fame, with a National Institutes of Mental Health psychiatrist version of Dr. Fauci urging research teams from around the world to scale up the manufacture of soma ASAP? I’m only being slightly facetious. The dominant school of medicine hasn’t shown much interest in non-pharma approaches relative to host susceptibility, for instance, in response to COVID-19’s physical challenges.

Toward a new integrative strategy for mental health

Lake: I haven’t thought about the scenario you’ve outlined, but given the hegemony of the pharmaceutical industry I wouldn’t put it beyond the realm of possibility. My guess is there are people who spin drug ads who may already be trying to figure out how to create pharmaceutical ads to take advantage of the crisis, for example, by targeting antidepressants or anxiolytic drugs at ‘the stress and despair’ of dealing with Covid19 day to day. This is why I am calling for a re-thinking of current models of care, a re-thinking of conventional approaches to mental health care, and bringing evidence-based complementary and integrative approaches into the conversation.  It is time to bring together people from the National Center for Complementary and Integrative Health, the National Institutes of Mental Health, the American Psychiatric Association, the American Psychological Association, and experts in complementary and alternative medicine to join forces and propose a coherent national strategy.

Integrator: A piece of good news of which you might not be aware is that the NCCIH has an initiative to research stress reduction methods, whether as Apps or other remote delivery, that are effective in the context of social distancing. What do you think needs to change? What can the integrative world bring to an emerging mental health pandemic to warrant being at that table?

Lake:  One area is to broadly promote a collaborative model of care in which patients are seen in the same clinic for medical and mental health problems, where they are educated about the benefits of healthy lifestyle choices and offered both conventional and CAM approaches. We need to have behavioral health providers working together with primary care doctors. We need to emphasize educating our patients so that they can enhance resilience in the face of chronic stress. As the pandemic continues, I think there will be a more central role for what is called “lifestyle medicine.” Exercise alone, just moving the body can be a strong support in lifting one out of depression. Sometimes people just need a 20-minute walk. Few people understand how important nutrition is for mental health, and how certain food choices can improve depressed mood and anxiety.  People need to helped to become more self-sufficient. Along these lines a key factor in mental health is locus of control. The belief that you have control over what happens to you—agency in your own life—is key to overcoming fear and despair. Spiritual work and affiliation to a religious group will be very helpful for many who are struggling with deep-seated anxiety and despair. We are doctors—from docere ‘to teach’ we need to embrace our calling to teach and to educate the public.

Integrator:  If it’s docere we need, this kind of teaching, then we have a strong incentive to promote group-based integrative models. Adults like to learn interactively. Groups are an antidote to loneliness. These are contexts that foster empowerment and strengthen a sense of agency and of community. People learn communication skills.

Lake: I think that collaborative care with a focus on integrative medicine can be enhanced through groups.

Integrator: Is it a safe assumption that those who will be hardest hit by such a second pandemic will be those with the fewest resources, – as we’ve learned is the case with COVID-19’s physical challenges?

Lake: Yes, I think that’s a valid assumption. Here in Monterey and many other places in California many people are afraid even to come for care of any kind for fear that they will be reported to ICE [immigration] agents. As I said in the column, the mental health services and resources that emerge from a national strategy should be freely available to everyone who can’t otherwise afford them.

Integrator: What do you see as the role of the integrative health community?

Lake: I see this from the perspective of a clinician, not an academic. How we work with patients counts most, there is nothing more important. How we communicate with our patients and how they feel about themselves when we talk with them, that counts. What you write also counts if it changes the way someone thinks or takes care of themself. It’s about docere. We are teachers, guiding patients to deeper levels of understanding. It’s important for us to invite discussion and debate on this. We need to get this discussion to the right tables. Then things will start to happen.

Integrator: Well I’ll check with an Academic Collaborative for Integrative Health connection with the National Academy of Medicine to see what may be going on there – if there are emerging plans. There are signs that they are seeing the complexities of the COVID-19 overlapping with the opioid crisis. NAM is also a likely place for a convening.

Lake: Thanks. What we need is a coordinated, coherent national response to this emerging crisis before it gets too late.

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Comment: Possible Integrative Contributors to Unwind a Mental Health Pandemic

The case for a coming mental health crisis of pandemic proportions is unfortunately compelling. The United Nations published a Policy Brief in May 2020 (see below) urging a “whole of society” approach. Lake’s prescription for advancing new strategies seems headed in the right directions. Yet clearly the column itself only hints at the detail needed to flesh it the integrative components.

What can integrative health offer? I asked integrative psychiatrist Scott Shannon, MD to look at Lake’s column. He pretty well accepted the premise that we have a mental health mess of huge proportions ahead of us. Shannon urged the use of groups. He also thought that delivering programs through schools merited focus and that there are more specific complementary and integrative methods that might be useful.

After musing on the topic with Lake, and hearing Shannon’s response, I began to imagine some possible contributors to answering a mental health pandemic be? Some possible contributors:

1. Is there a role, for instance, for the nation’s 280,000 plus massage therapists?
2. How about for the group-delivered acupuncture services of the nationwide network of the People’s Organization of Community Acupuncture (POCA) movement?
3. Is this the time to role out the public health strategy for mindfulness that researchers associated with the Benson-Henry Institute advocated at the end of a retrospective search article that found huge reductions in utilization of medical services among those who had used such services?
4. How about expanding the use of certified citizens serving other citizens in Wyoming’s pioneering National Acupuncture Detoxification Association (NADA) model?
5. Might this be the time for the Whole Health Institute to spearhead rolling out in the civilian population the peer-to-peer whole health coaching for finding agency and engaging healthy practices pioneered in the VA?
6. Give stresses on children, and the long-term nature of the challenges, promoting the K-12 Whole Health Education models being advanced by integrative pediatrician Larry Rosen, MD and longtime integrative care organizer Taylor Walsh such as was suggested by Shannon?

Any strategy that brings people together, to feel and experience community, will likely nudge resilience markers positively. What are all the means to do that? Lake alluded to the additional fear and distress many feel based on the reckless, erratic hate speech that is sewing greater divisiveness from the top spot in the US government. The most effective, enduring – and also group oriented method method of delivering the therapy — may be the medicine of an electoral college victory for someone new in the Oval Office.

Noted resource: United Nations, May 2020: Policy Brief: COVID-19 and the Need for Mental Health Action

The report recommends these 3 areas of action:

1. Apply a whole-of-society approach to promote, protect and care for mental health.
2. Ensure widespread availability of emergency mental health and psycho-social support.
3. Support recovery from COVID-19 by building mental health services for the future.

In addition, the very limited CDC fact sheet on stress and coping during COVID-19 is here.