Southern California PSYCHIATRIST September 2026

Between Healing and Hindrance: The Influence of Faith in Psychiatric Care

by Vanessa Markgraf, MD and Mubarak Sanni

“You just mentioned God—do you feel like faith has an important role in your life?” There are only a few specialties that address religiosity directly—not just from a perspective of determining which care a patient will accept or decline, such as blood transfusions, but on the premise of how their beliefs can influence their levels of psychological distress. Moreover, the fields of palliative medicine and psychiatry are especially unique within the field of medicine because inherent to our interviews are the establishment of trust, comfort, and communication while patients are in their most vulnerable emotional states. During psychiatric interviews patients frequently describe how their faith has gotten them through the hardest times of their lives, providing them with a sense of meaning or serving as a protective factor against suicide because “I could never do that–it’s against my religion.”

For these patients, evaluation using a standardized suicide risk assessments reveals the influences of their faith on their hopefulness for the future and social supports, as well as the presence of faith itself being a protective factor. For some patients, however, the solitary reliance on faith led to delayed care after years of depressive symptoms. Their suffering was seen as a reflection of “my weak faith and that I wasn’t praying enough” rather than mental illness. In this case, spiritual coping failed to adequately address their symptoms, as it was used instead of psychiatric care rather than in conjunction with it. Additionally, there are also groups in which religion can cause harm, such as those within restrictive religions who identify as part of the LGBTQ+ spectrum. Religion then, when superimposed on psychiatric care, exerts effect modification—in other words, its effect varies across different groups. These varied patient experiences illustrate a central tension: faith can function simultaneously as refuge and risk, offering resilience, community, and meaning while also shaping how mental health is interpreted and treated. In the Hinduism and the monotheistic religions of Christianity, Orthodox Judaism, and Islam alike, suicide is prohibited, and life is viewed as entrusted by God.

How then does spirituality influence psychiatric care in countries where the religious institutions are deeply woven into social life and mental illness is frequently understood through spiritual frameworks? Mental health conditions affect an estimated 20-30% of the population in Nigeria, yet only a fraction of those affected access formal psychiatric care.¹ In Peru, for example, mental and substance use disorders accounted for the largest component of disability adjusted life years, which are accounted for by taking the sum of years of life lost and years lost due to disability.² In India studies showed that nearly 150 million individuals suffer from one or more mental morbidities with a treatment gap of 84.5%.³ In these three countries, those who identify as religious range from 95% in Peru to 99% in both India and Nigeria, compared with only 72% in the US.^4,5,6,7

Religious institutions frequently become the first point of contact because they are trusted, accessible, affordable, and deeply embedded within communities. For example, within some Nigerian traditions, such as Yoruba healing practices, health is viewed as extending beyond physical wellbeing and instead conceptualizes wellness as a state of balance among the individual, community, ancestors, and divine forces. Within this framework, seeking guidance from religious leaders is seen as an essential component of understanding suffering and restoring balance. In a study of psychiatric patients in Kano, many participants attributed mental illness to supernatural causes, while nearly half reported initially pursuing religious healing before seeking biomedical care.⁸ Psychiatry therefore faces an important challenge: learning to engage with spirituality neither dismissively nor uncritically, but with cultural humility and clinical nuance. How can we meet patients where they are—whether inpatient, outpatient, or those in the community not actively seeking care, and effectively communicate about mental health?

In a city of migrants, with foreign-born residents comprising between 38-40% of the total population, it is essential to develop frameworks that meet people where they are and expose them to mental health care.⁹ If we challenge directly and tell patients that they should focus on seeking medical care instead of relying on their religion, we have a risk of activating the backfire effect—a psychological phenomenon where a correction leads to increased belief in the very misconception that it attempted to correct.¹⁰ Instead, the best way to approach patients who would otherwise be resistant to receiving mental healthcare can be starting with a question “can you tell me more about why you think that?” These moments may offer an opportunity to better understand the patient’s upbringing, values, concerns, and sources of support. Furthermore, these questions can help strengthen the therapeutic alliance by providing patient-centered care.

Simple interventions can make a meaningful difference. Hospitals may consider expanding access to multifaith spaces where patients can pray, reflect, or engage in spiritual practices to improve inpatient care. Providing prayer mats, religious texts, or facilitating visits from chaplains can help patients feel seen during vulnerable moments. Even in settings where resources are limited, a clean blanket can be used as a prayer mat and can reinforce a patient’s sense of dignity and belonging. When appropriate, we can also engage family members through psychoeducation to dispel misconceptions that mental illness reflects personal weakness and bad faith. Relatives can be among the first to recognize behavioral changes in their loved ones and can encourage patients to proactively seek treatment.

Aside from just integrating one question into our intake interviews, we can also liaison with community leaders who have already found ways to bridge the gap between mental health needs in the community and formal psychiatric care. Partnerships already exist between mental health professionals and faith-based organizations, such as Shower of Hope, which regularly deploys its mobile hygiene trailers across church parking lots in LA. Aside from providing the resources for unhoused individuals to shower, they also provide free meals, haircuts, and other resources to access housing support and mental health services.¹¹ Substance Abuse and Mental Health Services Administration (SAMHSA) also has local branches and encourages faith and community leaders to promote mental health awareness by educating their congregations and communities through forums and other educational opportunities.¹²

Because clergy members are often among the first individuals approached when someone experiences depression, anxiety, psychosis, or suicidal thoughts, training religious leaders in mental health first aid and suicide prevention may facilitate earlier recognition of psychiatric symptoms and more timely referrals to professional care. Such initiatives have the potential to reduce stigma, improve mental health literacy, and strengthen pathways to treatment in underserved communities. Muslims Understanding and Helping Special Education Needs (MUSHEN) was founded by Dr. Omar Suleiman and Sr. Joohi Tahir in response to a witnessed need—that individuals with disabilities and their families were inadvertently excluded from religious spaces. In Southern California alone, the Islamic Center of Irvine, Islamic Institute of Orange County, and the Islah LA have all been MUHSEN certified¹². By interfacing with these types of inclusive programming already established by community leaders, we can create opportunities to intersect with community members that would have otherwise not been possible.

Ultimately, the question is not whether religion belongs in psychiatric care, because for many of our patients their mental health and faith are inextricable. Instead, the question becomes how we engage with it. We can help to amplify the positive effects of faith by providing religious support through chaplain services while inpatient and engaging with community liaisons to expand the reach of mental health care while outpatient. We can hopefully also limit the negative effects of religion by carefully challenging beliefs that contribute to stigma, delay treatment, or complicate recovery after establishing a therapeutic relationship and rapport with our patient. By approaching conversations about faith with humility and cultural competency, we can better engage with patients’ beliefs to identify opportunities for intervention that would otherwise be missed. Psychiatrists have hundreds of tools in our toolbelts to engage with our patients and in an increasingly diverse society, culturally responsive psychiatry is simply one more that we can use to create meaningful engagement with our diverse patient populations.

Citations:

1. Jidong D, Ike T, Dada S …A Qualitative Study of Religious Beliefs About Mental Health in Nigeria The American Journal of Geriatric Psychiatry Open Science, Education, and Practice, 2025; 9, 52-60
2. Alva-Diaz, C., Huerta-Rosario, A., Molina, R. A., Pacheco-Barrios, K., Aguirre-Quispe, W., Navarro-Flores, A., … & Sanchez, R. R. (2022). Mental and substance use disorders in Peru: a systematic analysis of the Global Burden of Disease study. Journal of Public Health, 30(3), 629-638.
3. Gautham, M. S., Gururaj, G., Varghese, M., Benegal, V., Rao, G. N., Kokane, A., … & Shibukumar, T. M. (2020). The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. International Journal of Social Psychiatry, 66(4), 361-372.
4. Association of Religion Data Archives. (n.d.). National profile: Peru. The ARDA. https://www.thearda.com/world-religion/national-profiles?u=177c
5. Association of Religion Data Archives. (n.d.). National profile: India. The ARDA. https://www.thearda.com/world-religion/national-profiles?u=108c
6. Association of Religion Data Archives. (n.d.). National profile: Nigeria. The ARDA. https://www.thearda.com/world-religion/national-profiles?u=166c
7. Pew Research Center. 2025. “2023-24 U.S. Religious Landscape Study Interactive Database.” doi: 10.58094/3zs9-jc14.
8. Abilawon, S., & Adelagan, J. A. (2025). The Integral Spirit: Understanding Spirituality in Yoruba Traditional Healing practices. Research Journal of Humanities and Cultural Studies, 11(5).
9. Moreno, C., Duncan, K., Gonzalez, D., & Le, T. (2024). State of immigrants in Los Angeles County 2024 (5th annual report). USC Equity Research Institute & California Community Foundation. https://dornsife.usc.edu/eri/wp-content/uploads/sites/41/2024/07/Final_SOILA2024_Full_Report_v3.pdf
10. Swire-Thompson, B., Miklaucic, N., Wihbey, J. P., Lazer, D., & DeGutis, J. (2022). The backfire effect after correcting misinformation is strongly associated with reliability. Journal of Experimental Psychology: General, 151(7), 1655.
11. The Shower of Hope. (n.d.). The Shower of Hope. https://www.theshowerofhope.org/
12. Substance Abuse and Mental Health Services Administration. (2026, March 13). How to talk to community and faith leaders about mental health. U.S. Department of Health and Human Services. https://www.samhsa.gov/mental-health/what-is-mental-health/how-to-talk/community-and-faith-leaders
13. https://muhsen.org/

SCPS Participates in Reception for Xavier Becerra in Claremont

by Roderick Shaner, MD

On August 20, members of the SCPS Council traveled to Claremont to attend a reception for Xavier Becerra, the Democratic nominee for California State Governor. The event, held at a private residence, brought together supporters from across our local region’s medical and civic communities.

SCPS was represented by Laura Halpin, MD (President), Ijeoma Ijeaku, MD, Gillian Friedman, MD, Galya Rees, MD, and myself in my role as the SCPS representative to the California State Association of Psychiatrists (CSAP) PAC. CSAP, which represents all five California APA District Branches, has supported the nominee through the CSAP PAC. Mr. Becerra previously served as U.S. Secretary of Health and Human Services, a role in which he oversaw national health policy and federal agencies central to behavioral health.

Mr. Becerra offered brief remarks outlining his priorities, including a commitment to protecting the health and safety of Californians and resisting federal policies that undermine access to care.

Events such as this allow CSAP and its District Branches to maintain constructive relationships with policymakers and ensure that the perspectives of California psychiatrists remain part of statewide discussions. Our SCPS group also had the opportunity to meet the candidate and take a photo with him.

As part of our efforts to keep members informed about CSAP’s advocacy activities throughout the election season, we want to share the CSAP position paper that summarizes CSAP Legislative Priorities for 2026-2027. CSAP-2026-27-Proporities.pdf. Very briefly, the paper outlines our three top legislative priorities in a way that legislators can quickly understand:

1. Expand and ensure access to evidence-based psychiatric treatment across the continuum of care.
2. Prioritize and Modernize Care for Californians with Severe Mental Illness and Severe Substance Use Disorders.
3. Establish comprehensive statewide quality monitoring for county mental health systems.

Make Life Better for You, and Your Patients: Diagnose Cluster B Personality Disorder

by Carl Fleisher, MD

“I think it makes sense to consider whether a different diagnosis can help us explain the difficulties you’ve described.”

Narcissistic and borderline personality disorders (NPD and BPD) are impairing, associated with disproportionate health care utilization, and can challenge clinicians. Psychiatrists are increasingly expected to demonstrate basic competence in diagnosing and treating personality disorders (Price et al., 2025). Accurate diagnosis and treatment can reduce clinicians’ burden by making patients’ behavior more understandable, fostering competence, replacing therapeutic nihilism with realistic hope, and reducing pressure to “fix” self-harm or “save” patients’ lives (Masland et al., 2018).

Establish the Diagnosis

Screening measures such as the 10-item McLean Screening Instrument for BPD (MSI-BPD; Zimmerman et al., 2021) or the 12-item Level of Personality Functioning Scale-Brief Form (Hutsebaut et al., 2016) offer a rapid first step. Positive screens should be followed by a clinical interview (Furtado Fernandes et al., 2026).

Personality disorders can be distinguished from primary mood disorders by interpersonal reactivity, mood shifts lasting hours to days, identity disturbance, and self-harm or other risky behavior (Bohus et al., 2021). Asking for patients’ input about each DSM-5-TR criterion provides a structured, collaborative approach while minimizing the message that there is “something wrong” with the patient.

Tell the Patient

“Making sense of something is always a good thing.”

Patients should be told their diagnosis compassionately. “Narcissism” is highly stigmatized, but the underlying process can be viewed sympathetically: hypersensitivity to shame can lead people to rely excessively on external validation for self-esteem. Similarly, people with BPD may be hypersensitive to exclusion, leading to overreliance on romantic relationships; the need for connection is normal.

A straightforward explanation:

“From what you’re describing, it seems like your brain is overly sensitive to outside indicators of [caring, for BPD / importance, for NPD]. This can leave you vulnerable to overreacting, blaming others, or coping in unhealthy ways.”

Clinicians sometimes worry that disclosure is stigmatizing, but withholding a diagnosis may perpetuate stigma by treating the diagnosis as too shameful to discuss openly. Guidelines and lived-experience research support this view. Naming the disorder can foster a coherent self-narrative, preserve autonomy, reassure patients they are not “bad” or “broken,” direct them toward effective treatment, and counter misinformation (Proctor et al., 2021; Bohus et al., 2021). Disclosure can also strengthen the therapeutic alliance and facilitate psychoeducation (Leichsenring et al., 2023).

Psychoeducation as Treatment

“Understanding your illness is an important step toward getting better.”

Psychoeducation can have therapeutic effects. In a controlled trial, a six-session psychoeducational group improved nearly all BPD symptom domains, with benefits sustained at two-month follow-up (Ridolfi et al., 2019). Patients with NPD have likewise reported psychoeducation as useful and satisfying (Blay et al., 2026).

Psychoeducation should begin when the diagnosis is made. It is accessible, inexpensive, and generalist psychiatrists can either deliver it or refer patients to relevant online information (Choi-Kain et al., 2026).

Prognosis

“Good news: this is likely to get better, especially if you keep working or stay in school.”

The prognosis for symptom reduction is good, and patients should be told so (Zanarini et al., 2012; Gunderson et al., 2011). Acute behavioral symptoms (e.g., self-harm, drug misuse) gradually remit and rarely recur (Temes & Zanarini, 2018). In the McLean Study of Adult Development, 86% of 290 patients with BPD achieved symptomatic remission lasting at least four years (Zanarini et al., 2010). Yet, the same study showed that affective and interpersonal symptoms persist, while functional recovery lags even further. Only 50% of patients in that study achieved “full” recovery, defined as remission plus good social and vocational functioning.

Communicating this trajectory provides realistic hope, tempered to ensure patients focus on non-romantic challenges.

Treatment = Goals + Fewer Pills

Avoid piling on the pills…

Good Psychiatric Management (GPM) provides a structured, generalist approach that is simple to learn and deliver. GPM incorporates goal-focused appointments, psychoeducation, rational boundaries, and a pragmatic approach. In a large Canadian trial, GPM was as effective as DBT on key outcomes, including BPD symptom severity (McMain et al., 2009).

No medication is FDA-approved for BPD or NPD, nor do medications improve their core symptoms. Psychiatrists should therefore resist the temptation that medicine can target specific symptoms (a mood “stabilizer”) and, especially, polypharmacy. Polypharmacy clouds any determination of usefulness, undermines patients’ already low sense of agency, exposes patients to adverse effects, and may eventually reinforce demoralization.

Pharmacotherapy is best used as a time-limited adjunct for comorbid disorders or acute crises (Leichsenring et al., 2023). When prescribing, establish a simple, measurable target, a defined duration, and an explicit time to stop and reassess. Decisions should be collaborative and anchored in an overall treatment plan centered on psychotherapy. For acute crises, non-addictive agents can supplement coping skills; benzodiazepines should be avoided. For patients taking benzodiazepines, DBT skills training alone has reduced their use (Soler et al., 2022).

Repetitive transcranial magnetic stimulation (rTMS) is an approach that holds promise (Tadayonnejad et al., 2026; Konstantinou et al., 2021; Zou et al., 2023). Preliminary studies suggest that rTMS, unlike ECT, can be effective for depression comorbid with BPD (Feffer et al., 2022).

Therapy:  Don’t Wait for a Three-Letter Acronym

“Let’s not wait; any therapy that targets your symptoms is likely to help.”

There will never be enough therapists trained in specialized BPD treatments. Specialized psychotherapy for NPD remains underdeveloped. Research nevertheless suggests that psychotherapy, specialized or otherwise, helps patients with personality disorders (Storebø et al., 2020). This likely reflects shared or “common” factors (Wampold, 2015; Bohus et al., 2021).

Patients can therefore be referred to any available therapy, provided the therapist discusses the diagnosis openly and targets relevant symptoms. Of the specialized BPD treatments—DBT, mentalization-based therapy, transference-focused psychotherapy, and schema therapy—none is clearly superior to the others (Arntz et al, 2022; Cristea et al., 2017; Bohus et al., 2021).

Summary

Personality disorders are treatable conditions with a generally hopeful prognosis. For psychiatrists, a generalist approach – naming the diagnosis, providing psychoeducation, limiting medication and offering any goal-focused psychotherapy – can improve outcomes while also reducing clinician burden and increasing their satisfaction.

 

References

1. Arntz A, Jacob GA, Lee CW, Brand-de Wilde OM, Fassbinder E, Harper RP, Lavender A, Lockwood G, Malogiannis IA, Ruths FA, Schweiger U, Shaw IA, Zarbock G, Farrell JM. Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2022 Apr;79(4):287-299.
2. Blay M, Benmakhlouf I, Speranza M, Duarte M, Ronningstam E. Feasibility and Acceptability of a Group Psychoeducation Program for Patients With Pathological Narcissism With or Without a Diagnosis of Narcissistic Personality Disorder. J Psychiatr Pract. 2026 Jul;32(4):166-173.
3. Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet. 2021 Oct;398(10310):1528-1540.
4. Choi-Kain LW, Crisp DJ, Mermin S, Murray GE, Jurist JB, Masland SR, Mosby M, Germine LT, Ren B. Online psychoeducation and assessment for borderline personality disorder as a first step of care: A pilot study assessing safety, feasibility, and mechanisms of change. PLoS One. 2026 Aug;21(8).
5. Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2017 Apr;74(4):319-328.
6. Feffer K, Lee HH, Wu W, Etkin A, Demchenko I, Cairo T, Mazza F, Fettes P, Mansouri F, Bhui K, Daskalakis ZJ, Blumberger DM, Giacobbe P, Downar J. Dorsomedial prefrontal rTMS for depression in borderline personality disorder: A pilot randomized crossover trial. J Affect Disord. 2022 Mar;301:273-280.
7. Furtado Fernandes L, Davis MT, Luo W, McAfee TM, Jones KG, Chandler G, Fineberg SK. Good enough assessment: A comparison of brief screener and detailed interview assessments of borderline personality disorder symptoms in a clinical research setting. Personal Disord. 2026 Sep;17(5):340-350.
8. Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini MC, Yen S, Markowitz JC, Sanislow C, Ansell E, Pinto A, Skodol AE. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Arch Gen Psychiatry. 2011 Aug;68(8):827-37.
9. Hutsebaut J, Feenstra DJ, Kamphuis JH. Development and Preliminary Psychometric Evaluation of a Brief Self-Report Questionnaire for the Assessment of the DSM-5 level of Personality Functioning Scale: The LPFS Brief Form (LPFS-BF). Personal Disord. 2016 Apr;7(2):192-7.
10. Konstantinou GN, Trevizol AP, Downar J, McMain SF, Vila-Rodriguez F, Daskalakis ZJ, Blumberger DM. Repetitive transcranial magnetic stimulation in patients with borderline personality disorder: A systematic review. Psychiatry Res. 2021 Oct;304:114145.
11. Leichsenring F, Heim N, Leweke F, Spitzer C, Steinert C, Kernberg OF. Borderline Personality Disorder: A Review. JAMA. 2023 Feb;329(8):670-679.
12. Masland, S. R., Price, D., MacDonald, J., Finch, E., Gunderson, J., & Choi-Kain, L. Enduring effects of one-day training in Good Psychiatric Management on clinician attitudes about borderline personality disorder. The Journal of Nervous and Mental Disease, 2018;206(11), 865–869.
13. McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 2009, 166(12), 1365–1374.
14. Price DG, Quayle WM, Unruh BT. Update on Psychiatry Residency Training in Personality Disorders: Becoming a Good Psychiatrist Through Becoming “Good Enough” at Treating Borderline and Narcissistic Personality Disorders. Curr Psychiatry Rep. 2025 May;27(5):255-266.
15. Proctor JM, Lawn S, McMahon J. Consumer perspective from people with a diagnosis of Borderline Personality Disorder (BPD) on BPD management-How are the Australian NHMRC BPD guidelines faring in practice? J Psychiatr Ment Health Nurs. 2021 Aug;28(4):670-681.
16. Ridolfi ME, Rossi R, Occhialini G, Gunderson JG. A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder. J Clin Psychiatry. 2019 Dec;81(1).
17. Soler J, Casellas-Pujol E, Fernández-Felipe I, Martín-Blanco A, Almenta D, Pascual JC. “Skills for pills”: The dialectical-behavioural therapy skills training reduces polypharmacy in borderline personality disorder. Acta Psychiatr Scand. 2022 Apr;145(4):332-342.
18. Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020 May;5(5):CD012955.
19. Tadayonnejad R, Gera R, Chu SA, Hawkins H, Hovhannisyan E, Ngo TDP, Corlier J, Leuchter AF. Ventrolateral prefrontal-amygdala repetitive transcranial magnetic stimulation (rTMS) modulation of impulsivity in borderline personality disorder: a proof-of-concept study. Sci Rep. 2026 Jun;16(1):26833.
20. Temes CM, Zanarini MC. The Longitudinal Course of Borderline Personality Disorder. Psychiatr Clin North Am. 2018 Dec;41(4):685-694.
21. Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct;14(3):270-7.
22. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. Am J Psychiatry. 2010 Jun;167(6):663-7.
23. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry. 2012 May;169(5):476-83.
24. Zou M, Broadbear JH, Rao S. Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review. J ECT. 2023 Sep;39(3):151-157.
25. Zimmerman M, Balling C. Screening for Borderline Personality Disorder With the McLean Screening Instrument: A Review and Critique of the Literature. J Pers Disord. 2021 Apr;35(2):288-298.

From Concept to Clinic: Integrating ‘Ikigai’ into Mental Health Care

by Onyinye Onwuzulike, MD

https://onlinelibrary.wiley.com/doi/pdf/10.1002/lim2.70018

Cultural factors continue to play a significant role in shaping the health outcomes of individual patients. The relationship between culture and health continues to evolve, with a growing discussion in which traditional approaches to healthcare alone, specifically mental health care is not enough. This scoping review outlines the concept of Ikigai as a ‘reason to live’, utilizing the social and cultural aspects of health as non-traditional philosophies that can be helpful when treating individuals with mental health conditions. The aim is to provide a comprehensive overview of the current knowledge regarding Ikigai and its implications for clinical practice and future research. Our discussion suggests that Ikigai positively influences mental states like depression and helps cultivate a sense of purpose that improves overall well-being and life satisfaction.

A preliminary literature review determined the scope of articles focused on Ikigai, which were about 403. These studies were uploaded to Covidence, a screening tool used for reviewing articles. After the review, about 196 articles remained. These articles were screened further by the abstract screening process. 66 studies were excluded and 130 articles were included through an inclusion and exclusion criteria. Some of these criteria included articles that didn’t mention Ikigai, were not peer-reviewed, those not written in English, had limited access to the full text and articles published before 1960. After this process 86 studies remained. The articles were synthesized through a qualitative approach by similarities in study trends/characteristics and then main findings of the study. For example, Ikigai and people’s ability to connect with others in work, school, retirement communities, and/or other social environments was categorized by the trend of social connectedness.

Higher Ikigai was shown to present with lower depressive symptom severity. Ikigai correlated negatively with measures of depression and predicted greater scores of mental well-being [1]. Having Ikigai was associated with decreased depressive symptoms, hopelessness, as well as higher happiness and life satisfaction, decreased psychological distress, and improved subjective wellbeing [2].

Ikigai was also associated with reduced symptom scores. There were greater scores of mental well-being and lower depression scores, decreased depressive and anxiety symptoms, and associations with higher levels of happiness and higher levels of life satisfaction [3], even among family members who are caregivers [4-6]. Ikigai also decreases addiction to alcohol through strengthening psychological defense [7].

Individuals with Ikigai had a lower risk of developing neuropsychiatric conditions. There was shown to be a 36% lower risk of dementia compared to individuals without Ikigai [2]. Not having Ikigai was associated with poor intellectual activity [8], whereas having Ikigai was linked to a decreased risk of intellectual dysfunction [9].

Ikigai is not meant to be a stand-alone cure in mental health treatment, as there are limitations discussed in the data. There is a need to consider and explore the mechanisms driving the associations seen in this review. Does Ikigai seem to be protective against the development of depressive symptoms? Alternatively, could there be underlying depression that could possibly have a negative affect on Ikigai and therefore worsen a patient’s symptoms and overall well-being?

Ikigai is a combination of not only an external reason to live such as hobbies, relationships or goals one wants to achieve but an internal reason to live. This consists of the subjective perception that one’s daily life is worth living and that it is full of energy and motivation [10, 11]. Among older Japanese residents who participated in community based activities, there were statistically significant connections between Ikigai scores and self-rated health and mental health, as well as correlations between self-rated Ikigai scores and social participation, self-rated health, and mental health [12].

Shifting Ikigai from an idea to a framework that is weaved into clinical practice would require initial screenings to assess a patient’s understanding of their purpose or lack thereof. Deeper discussion of hobbies, interpersonal relationships and family dynamics can also be done during initial patient intake and follow up interviews. Healthcare professionals can integrate value based psychotherapies such as meaning-centered or commitment therapy and DBT, while also encouraging social engagement and interpersonal activity; patients can further explore what they believe they have to live for and what their future goals are. Paired with traditional mental health treatment, patients can face and overcome the psychosocial triggers that are negatively affecting their behavior.

1. D. Fido, Y. Kotera, and K. Asano, “English Translation and Validation of the Ikigai-9 in a UK Sample,” International Journal of Mental Health and Addiction 18, no. 5 (2020): 1352–1359.
2. S. S. Okuzono, K. Shiba, E. S. Kim, et al., “Ikigai and Subsequent Health and Wellbeing Among Japanese Older Adults: Longitudinal Outcome-Wide Analysis,” Lancet Regional Health—Western Pacific 21 (2022): 100391.
3. A. Hajek, T. Imai, L. Zwar, and H.-H. König, “Translation and Validation of the German Version of the Ikigai-9,” Societies14, no. 3 (2024):
4. N. Yamamoto-Mitani and M. I. Wallhagen, “Pursuit of Psychological Well-Being (Ikigai) and the Evolution of Self-Understanding in the Context of Caregiving in Japan,” Culture, Medicine and Psychiatry 26 (2002): 399–417.
5. N. Yamamoto-Mitani, K. Ishigaki, M. Kuniyoshi, et al., “Impact of the Positive Appraisal of Care on Quality of Life, Purpose in Life, and Will to Continue Care Among Japanese family Caregivers of Older Adults: Analysis by Kinship Type,” [Nihon Koshu Eisei Zasshi] Japanese Journal of Public Health 49, no. 7 (2002): 660–671.
6. K. Okamoto and Y. Harasawa, “Predictor of Increase in Caregiver Burden for Disabled Elderly at Home,” Archives of Gerontology and Geriatrics 49, no. 1 (2009): 129–131
7. R. Ishida, “Proposal to Prevent Alcohol Dependence Using Purpose in Life/Ikigai to Mimic the Chemical Effects of β-Endorphin,” Psychology 3, no. 7 (2012): 534–536.
8. K. Tomioka, N. Kurumatani, and H. Hosoi, “Relationship of Having Hobbies and a Purpose in Life With Mortality, Activities of Daily Living, and Instrumental Activities of Daily Living Among Community-Dwelling Elderly Adults,” Journal of Epidemiology 26, no. 7 (2016): 361–370.
9. N. Nakanishi, I. Nakura, K. Nagano, et al., “Mortality in Relation to the Type of Household Among Elderly People Living in a Community,” Journal of Epidemiology 8, no. 1 (1998): 65–72.
10. S. Kono, G. J. Walker, E. Ito, and Y. Hagi, “Theorizing Leisure’s Roles in the Pursuit of Ikigai (Life Worthiness): A Mixed-Methods Approach,” Leisure Sciences 41, no. 4 (2019): 237–259.
11. S. Kono and G. J. Walker, “Theorizing the Temporal Aspect of Ikigai or Life Worth Living Among Japanese University Students: A MixedMethods Approach,” Applied Research in Quality of Life 16, no. 2 (2021): 845–873.
12. R. Nakao, A. Nitta, M. Yumiba, K. Ota, S. Kamohara, and M. Ohnishi, “Factors Related to Ikigai Among Older Residents Participating in Hillside Residential Community-Based Activities in Nagasaki City, Japan,” Journal of Rural Medicine 16, no. 1 (2021): 42–46.

September is FASD Awareness Month!

by Danielle Shaw, MD

September has been designated as FASD Awareness Month. September 9^th is International FASD Awareness Day representing the 9 months of gestation.  What are fetal alcohol spectrum disorders (FASDs) and why are they important?

FASDs are a group of conditions that can occur in individuals who were exposed to alcohol prenatally. Prenatal alcohol exposure (PAE) is the most common preventable cause of intellectual disability and behavior disorders. As a teratogen, alcohol can cause birth defects and irreversible brain damage leading to cognitive and behavioral deficits.  It has been conservatively estimated that 1-5% of first graders may have an FASD (May et al.).  In 2026 the CDC reported that 15.2% of pregnant women in the US reported current drinking, 4.9% reported binge drinking (4 or more alcoholic drinks on at least 1 occasion), and 2.2% reported heavy drinking in the last 30 days (Thomas et al.).  There is no known safe amount of alcohol consumption during pregnancy.

Fetal alcohol syndrome (FAS) with its characteristic facial features and growth deficits is one of many FASDs and is not the most prevalent diagnosis associated with PAE.  FASDs include FAS, partial FAS, alcohol-related birth defects, alcohol-related neurodevelopmental disorder and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE).  It is challenging to study a disorder when there are different categories of FASDs.  ND-PAE is in the DSM-5-TR as a condition for further study and is mentioned as an example of Other Specified Neurodevelopmental Disorder.  In this article, I will focus on ND-PAE.

The criteria for ND-PAE are as follows:

A. More than minimal exposure to alcohol during gestation ( ≥13 drinks per month during pregnancy (i.e., any 30-day period of pregnancy))

B. Impaired neurocognitive functioning (at least one):

1. IQ 70 or below
2. Impaired executive functioning
3. Impaired learning
4. Impaired memory
5. Impaired visual-spatial reasoning

C. Impaired self-regulation (at least one):

1. Impaired mood or behavior regulation
2. Attention deficit
3. Impaired impulse control

D. Impaired adaptive functioning (2 of the following including 1 or 2)

1. Communication deficit*
2. Impaired social communication and interaction *
3. Impaired daily living skills
4. Impaired motor skills

Prenatal exposure to alcohol can lead to changes in brain development which are permanent and manifest as the symptoms included in the ND-PAE diagnostic criteria.  How do you know to look for ND-PAE?  Screening for alcohol exposure during pregnancy can be done by all medical providers.  Mental health clinicians should also screen for prenatal alcohol exposure since this is often not documented in patients’ records when they are referred to mental health.  This should be done routinely in a nonstigmatizing manner.  There is a 5P’s Prenatal Substance Abuse Screen for Alcohol and Drugs.  The first P is Parents.  Is there a family history of alcohol or drug use (I also ask about caffeine, nicotine and marijuana since they are legal and less stigmatized).  The second P is for Peers who use alcohol or drugs.  The third P is for Partner who uses alcohol or drugs.  The fourth P is for Past use of alcohol or drugs.  Lastly, the fifth P is for Past month use of alcohol or other substances.  The American Academy of Pediatrics (AAP) has an FASD Toolkit on its website, which contains a sample screen for prenatal alcohol exposure.  I often ask about the parents’ attitude towards substance use and current use, ask about past use, and how far along the pregnancy was when it was recognized.  It is important to note that alcohol use during pregnancy can occur prior to recognition of the pregnancy.  Drinking alcohol during pregnancy was not intended to harm the fetus.  It can reflect baseline consumption patterns prior to pregnancy recognition, substance use disorders, or for individuals with trauma exposure, it can be used to “numb emotional pain”.  Each of these needs to be addressed with compassion.  It is challenging to determine prenatal alcohol exposure in patients who were adopted or in foster care.  It may also be challenging when seeing an adult who presents with symptoms of ND-PAE.

As a child and adolescent psychiatrist, many of the patients I see are referred to me for behavior problems. That should always lead to considering a neurodevelopmental disorder as the source of the problem.  Behavior is a form of communication.  The child is frustrated and acting out because nothing else works and the child lacks the ability to communicate in a more mature manner.  As you can see in the diagnostic criteria, the symptoms of ND-PAE overlap with other neurodevelopmental disorders.  For more details please see Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure in Pediatrics 2016 138(4).  It is often helpful to refer to psychology for psychological testing to assess neurocognitive functioning.  This can be helpful to make the diagnosis and to use a strength-based approach.  If the patient’s brain is currently incapable of doing a task, it is not helpful to tell the patient to “try harder” to do what is currently impossible and leads to poor self-esteem, frustration and worsening behavior.  It is like telling a person with only one hand to clap and tell him to try harder when he can’t succeed.  These patients become stigmatized.  We need to approach the patient with a paradigm shift.  We need to assess if an invisible brain-based disability is causing the difficulty rather than blaming the child for not being able to complete tasks (a “can’t” vs “won’t” concept). Ask yourself, “Is the child’s behavior related to a disability or defiance”.  Trying Differently Rather Than Harder addresses this approach to neurodiversity and is required reading for all my residents.  I also recommend it to help parents understand their child.

If the child meets the diagnostic criteria for ND-PAE, I use the recommendation in the DSM-5-TR and diagnose Other Specified Neurodevelopmental Disorder (F88) and add a comment about meeting criteria for ND-PAE.

FASDs are more prevalent in certain settings, including Regional Centers, Foster Care, Adoption and among individuals involved in the justice system.  Although so far, I have addressed diagnosis in pediatric patients, some individuals are not diagnosed until adulthood.  Some individuals with FASDs are involved with the justice system as minors or adults.  These individuals may be seeking a place to fit in and sometimes don’t understand consequences.  They can be taken advantage of by others who use them to do illegal acts for them.  Some individuals with FASDs function quite well and may even graduate college.  They often wonder why they must try so much harder than everyone else.  Obtaining a diagnosis and an understanding of how their brain works differently can bring relief and better understanding of their strengths and weaknesses.

Lastly, many professionals worry about making a diagnosis if they don’t know what to do next.  Advocacy is increasing access to resources in our community.  In California, FASD has been added to the educational code under Other Health Impairment and qualifies an individual for support through an Individualized Education Plan (IEP). FASD United has a Family Navigator Program that can help connect families with local resources.  There is also an FASD Support Network of Southern California.  Recently, the FASD Respect Act, as part of the SUPPORT Act, passed Congress and we are advocating for the appropriation of funds to improve resources for the diagnosis and treatment of FASDs.

My “why” for FASD and mental health advocacy comes from personal experience.  I adopted my daughter at birth, and she experienced mental health struggles. She was diagnosed with ADHD yet didn’t respond typically to treatment.  She wasn’t diagnosed with partial FAS until she was 19 years old when I enrolled her in a study at UCLA.  This led me to train in child and adolescent psychiatry after practicing general pediatrics for many years.  I am now a member of the AAP FASD Champions Network, and we seek to educate others about FASDs and improve access to diagnosis and treatment.

If you want to learn more about ND-PAE, you can attend the American Academy of Child & Adolescent Psychiatry (AACAP) Annual Meeting in October.  There will be a presentation “Disentangling the Developmental Origins of Challenging Behaviors: The Intersection of Prenatal Alcohol Exposure and Trauma”.  There is a Pediatric Tract for pediatric attendees.  I have included references and resources below.  The next time you see a patient, adult or child, with neurocognitive impairment, impaired self-regulation, and impaired adaptive functioning, put neurodevelopmental disorders on your differential diagnosis and consider ND-PAE.  I am grateful to colleagues at the AAP and CDC for their contributions to the editing of this article and their contribution to the upcoming AACAP presentation.

Resources:

American Academy of Pediatrics FASD Toolkit: https://www.aap.org/en/patient-care/fetal-alcohol-spectrum-disorders/

CDC FASD Homepage (includes information in Spanish)- www.cdc.gov/fasd

FASD United (Formerly NOFAS)- https://fasdunited.org/

• https://fasdunited.org/resource-directory
• Family Navigator Program is a great resource for families

FASD Network of Southern CA- https://fasdsocalnetwork.org/

Trying Differently Rather Than Harder: Rethinking Neurodiversity, Transforming Lives.  Alsup, Brassard and Elligson, 2025

References:

Thomas, Gosdin, Terplan, Kim and Deputy.  Alcohol Consumption During Pregnancy Among Women Aged 18-49 Years- United States, 2021-2024. CDC Morbidity and Mortality Weekly Report / June 11, 2026 / 75(22);280–284

Diagnostic and Statistical Manual-5-TR, American Psychiatric Association 2022

Hagan, J. F., Jr., Balachova, T., Bertrand, J., Chasnoff, I., Dang, E., Fernandez-Baca, D., Kable, J., Kosofsky, B., Senturias, Y. N., Singh, N., Sloane, M., Weitzman, C., Zubler, J., & Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure Workgroup; American Academy of Pediatrics. (2016). Neurobehavioral disorder associated with prenatal alcohol exposure. Pediatrics, 138(4), e20151553. https://doi.org/10.1542/peds.2015-1553

May PA, Chambers CD, Kalberg WO, Zellner J, Feldman H, Buckley D, Kopald D, Hasken JM, Xu R, Honerkamp-Smith G, Taras H, Manning MA, Robinson LK, Adam MP, Abdul-Rahman O, Vaux K, Jewett T, Elliott AJ, Kable JA, Akshoomoff N, Falk D, Arroyo JA, Hereld D, Riley EP, Charness ME, Coles CD, Warren KR, Jones KL, Hoyme HE. Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities. JAMA. 2018 Feb 6;319(5):474-482. doi: 10.1001/jama.2017.21896. PMID: 29411031; PMCID: PMC5839298.

a friendly reminder: please follow us on instagram!

SCPS is now on Instagram!
https://www.instagram.com/socalpsychiatricsociety/