Dr. Merlo is clinical professor of psychiatry at NYU Grossman School of Medicine, associate editor of the American Journal of Lifestyle Medicine, fellow of the American College of Lifestyle Medicine (ACLM) past chair of the Mental and Behavioral Health Member Interest Group, member of three committees in ACLM (Research, Climate Change, and Positive Psychology), contributing author to ACLM’s board review course, and founding chair of the APA Caucus on Lifestyle Psychiatry and has recently been appointment chair of the APA Presidential Workgroup on Lifestyle Psychiatry. She recently published a general-audience book, Restack: A New Approach to Dismantle the Blocks Holding You Back. In her new book, Merlo urges us to embrace our humanness with our imperfections and provides tools and practical suggestions to "restack" yourself in a way that is psychologically freeing.

Additionally, Merlo has published three academic books (Oxford University Press and Taylor and Francis) including Lifestyle Psychiatry: Through the Lens of Behavioral Medicine which expands the area of lifestyle medicine to include social determinants of health, psychological principles, and the bidirectionality of physical and mental health. Dr. Merlo completed her Master of Health Profession Education in the Research Track at Johns Hopkins University where she serves as an adjunct instructor helping other health professionals with their capstone projects.

There are many intersections, and we must look at what social determinants of health are. I know your audience will know this, but I usually just talk about the nonmedical factors that affect health: physical and mental health. And I think that we, historically, as healthcare providers who are psychiatrists and focusing on mental health, are aware of that concept of a downward drift. So, for those of us who may have mental health issues, the larger proportion of people with mental health issues will go down in socioeconomic status, in their earning capacity, because of their burden of mental health and their struggles. And then we have this false sort of situation that happens that more people in the lower socioeconomic status may have more mental health issues.

Then, on the other side of the equation, we also see many people who are already living in a place where they are struggling with resources, as well as with mental health issues. We see both sides of the spectrum and must remember that. As a person who has worked in urban areas for many decades, I can attest that we see a lot of children also struggling because they have been born into this environment where they have fewer resources in their communities. That does not mean that they do not have resources in their families. One of the parts I wrote in my recent book, Restack: A New Approach to Dismantle the Blocks Holding You Back, is that family support when people have fewer financial resources is stronger. And it is a model in my world that families can support each other and communities.

It can go either way. The intersection is very wide and deep, and we need to be aware of it because often, as healthcare professionals we tell our patients to just do these lifestyle interventions. Just buy whole foods. But if you have a food desert in your community, you will not be able to. I have had families sitting in my office crying and saying, “it takes me three buses to go to a grocery store, which takes three hours a day. I am not doing that.” So, what they do is they buy food where they are, and guess what? What they get is ultra-processed foods and foods that we would not consider healthy.

Let me tell you something that resonated with me and stuck with me for many decades. I am a child and adult psychiatrist, and I had a child patient come into my office, diagnosed with ADHD. It is a prevalent diagnosis. One in 10 or 12 kids will have that diagnosis. Many of them will be on stimulant medication. But this child came in because they were disruptive in the school, and here they were in my office. I found him to be a bright-eyed, positive child. His mother and his sister were sitting outside. As a child psychiatrist, I always have snacks and healthy foods available as we cannot talk effectively if the child is hungry. If they are missing their snack, or if they are missing their dinner, or because they are in my office, right? It is just cruel and unusual punishment. So, I always have those available, and the first thing he did was go for that jar, and he looked at it. I could see him being very polite, just sitting and talking to me but staring. I said, “You know, let us have a snack before we get started.” He looked at me and said, “Can my mom have one? Can my sister have one?” I said, “Of course.” We went outside, and I could see that he wanted food for himself but wanted to give it to his mom and sister. Then he came back, and he sat down with me. It was my first meeting, and I started asking him questions as he ate his snack. I asked, “Is there snack time at home?” He says, "Oh, no, my family, we don't eat at home. That is not what we do. We are never hungry.” And then I said, “Oh, you are never hungry?” and he says “No. That's not our thing." Then we went on and I asked what happened and why he was there. He says, "Let me lay it to you on the line. It is straightforward. The kid was trying to take my lunchbox and my food. I got the food from school, and if I hadn't fought him, he would have taken it, and I would not have eaten it. I was hungry then, so I would not have been able to eat it. And if I just let him go, it would have been the same problem. I would be expelled and not be able to eat. So, what do I have to lose? Let me fight him. I will get expelled anyway and unable to eat because I'm hungry at school." Instead of giving him a diagnosis of ADHD because he met all the criteria of that diagnosis, I went out into the waiting room and talked to the mother. We talked about resources, trying to get the resources she needed, and getting the other child the resources they needed because that is what they needed more than anything else.

It is absolutely important. Our surgeon general produced the loneliness epidemic, which was put out in 2023. It is a multi-100-page document that talks about social isolation as being pivotal in our health. One of the studies they cite talks about social determinants. Social isolation can be more deadly and cause more mortality than even smoking 15 cigarettes a day or having alcoholic beverages. Some data supports the idea that socialization is highly problematic for our under-resourced neighbors and partners. We find that if you are unhoused, that causes a severe problem because you do not have community support nearby. If you become incarcerated, lose your job, or cannot function in the environment and do not have those financial resources, then you lose all contact with people. There's housing insecurity and other aspects.

Once you start addressing those issues and getting people to connect again with community centers and other places, those resources can also support people. I know staying with families is sometimes hard if you have already moved away from them. However, creating social support can be pivotal. It is especially important because we sometimes lose our social connection, which could affect our ability to be cognitively and mentally healthy.

So financial stress is a severe problem. In how we function in healthcare, we have limited time to talk to and support our patients and their families, and it is a family issue. It is not a patient issue. We must get the family together, and one of the first things I do is ask if you can bring all the family members together or if we get them on the phone. Then, we talk to the family together. I need to know who a decision maker in the family is because sometimes they do not show up at the office. Who is the person earning money? Who is the person that's shopping? Who is the person that is paying the rent or wherever they are living?

At times, we arrange conference calls during the session. As a child psychiatrist, I understand the crucial role of family involvement. You can communicate with a child extensively, but the involvement of adults in their lives is indispensable. I follow the same approach as adults, ensuring their loved ones are engaged. Once you identify the decision-makers, you are conversing with individuals who can bring about positive changes in their families.

Afterward, it is helping them develop the resources and providing contact numbers to provide resources. They can get extra resources in every state in this country. In supporting patients, identifying where food banks are available is important. For example, people may not realize that some churches also have them; often, they are not advertised in the system. Financial stress is difficult, and you cannot talk about lifestyle first. You must address this. Lifestyle interventions will only happen after you address these issues.

That is important. I understand my job because I must ask more questions before discussing the interventions. Knowing who you are dealing with and what their cultural needs, biases, and belief systems are can be beneficial. Even after I ask questions, if there is a time limitation, I usually give two options and say, "If these don't work, what else do you think?" I engage my patients in the conversation because most patients come to us already thinking deeply about these issues. They are struggling in a significant way, and they know it. Ask them first what they have tried, what has worked, and what has yet to. Let them tell you. I cannot tell you how many families come to my office and say, “Thank you for understanding that I have tried it already. I may not have the financial resources. I may not be of your religion or the way that you think. But I do have my strengths in that area.” Another caveat is that cultural and religious diversity in families is important. Diverse groups believe there are ways to be an upright approach to health care. In medicine and medical school, they very, very rarely talk about those cultural diversities. It is becoming more common, but it is important for us to understand that even if we intervene if it does not fit into their cultural belief system, it is not going to be followed. Then, they will lose our trust in them, and we will, therefore, lose the ability to help them.

I want to talk to you about this book that came out recently. In the lifestyle medicine movement, we often talk about six pillars of what we need to do in lifestyle psychiatry. The way that I conceptualized this book is for a general audience. I will first talk about the foundation of brain health. Then, I talk about mental blocks, and then I talk about external barriers before I talk about the solutions, because if we have internal mental blocks, trauma, issues with our emotional regulation, or cognitive deficits that are not allowing us to live life, and then we also have external barriers, that's where the social determinants of health and burnout come in. I focus heavily on this because the current approach to giving interventions to people without understanding that they are going to be ignored before we address all these issues is very problematic.

Even in our financially under-resourced populations, there will still be internal and external issues around these other internal barriers. We may address the social determinants of health, but we may still have these other issues.