Good evening and welcome to the American Psychiatric Association's Mental Health Fireside Chat. My name is Dr. Regina James, and I serve as the Deputy Medical Director and the Chair for the Division of Diversity and Health Equity here at the American Psychiatric Association. I will serve as your moderator today. So let's move this along. Some of you might have participated, actually, in our webinar series last year where we initially launched the APA Fireside Chats. We focused on the mental health impact of COVID-19 on various communities of color, Black, Latino, Indigenous, and Asian. This year, we're continuing the Fireside Chats, but we wanted to look beyond sort of the traditional frameworks and really take into consideration a multidisciplinary approach to conversations around mental health equity. So tonight, you'll see experts from different disciplines who will bring their experience, their expertise, and their frameworks to the conversation to help us think through mental health equity and how we should move forward. Today, the topic of discussion and the title of our webinar is 123 Years Since W.E.B. Du Bois' Case Study, Social Determinants of Health Inequities Continue. So to set the stage, I'd like to share some key points and I hope will serve as a springboard for discussion for the panelists. So Healthy People 2030 defines social determinants of health as where one is born, live, learn, work, play, worship, and ages, and those factors impact your quality of life outcomes, your health outcomes, et cetera. Examples of social determinants of health can range, and a few select examples can be safe housing, transportation, racism, discrimination, education, income, language and literacy skills, and adverse childhood experiences. And as you know, research supports that social determinants of health are the strong drivers, about 80% of health outcomes. So the fact that social factors impact our health status is not a novel concept. It's been recognized for years. So if you use the benchmark of 123 years when W.E.B. Du Bois published his landmark study, The Philadelphia Negro, where Du Bois basically his research revealed the influence of socioeconomic conditions that contributed to Black health. So you can use that as a landmark, or if you'd like to utilize 2005 when the World Health Organization established their commission on the social determinants of health to really examine the effects of health outcomes by these social factors. So in either case, whether you're starting from 123 years or the year 2005 with the World Health Organization, today we are still dealing with the complex issue of the social determinants of health and how they impact health. And tonight we're actually going to focus specifically on social determinants of health and how they impact mental health outcomes. We want to, with our panelists tonight, to initially lay the foundation of what are the social determinants of health and have a better understanding of that, appreciate how social determinants of health impact mental health, discuss cultural and linguistic considerations that need to be taken into consideration, and hopefully talk about potential challenges and opportunities and how we can incorporate social factors at the point of clinical care with individuals who have mental illness and substance use disorders. So tonight we have a fantastic panel who will lead the discussion. We will first start off with a background of social determinants of health, and that will be led by Dr. Mario Sims. Dr. Sims is a full professor of medicine in the Department of Medicine at the University of Mississippi Medical Center. His background is in medical sociology, social epidemiology, with specific training in population health research. His current research focuses on social and psychosocial factors such as stress and racial discrimination and segregation on health outcomes. So Dr. Sims will start the conversation, and then Dr. Michael Compton will be the first panelist to reflect on Dr. Sims' presentation. Dr. Michael Compton is a professor of psychiatry at Columbia University and research psychiatrist at New York State Psychiatric Institute. Dr. Compton serves on a number of institutional, regional, and national committees. He is co-editor of the book Social Determinants of Mental Health. He is a fellow of the American College of Preventive Medicine and a distinguished fellow of the American Psychiatric Association. Dr. Compton's reflection will then be followed by a reflection from Dr. Bluebird Jernigan. Dr. Jernigan is a professor of rural health and executive director of the Center for Indigenous Health Research and Policy at Oklahoma State University. Her work focuses on intervention science that combines research with action for social change. She is the principal investigator and co-investigator of about 10 NIH studies, and in all of her work, she has focused on long-term mutually beneficial relationships with Indigenous communities that support tribal sovereignty and build the capacity of Indigenous communities to improve health. So before we continue, or before we get started, I want to take this opportunity to first thank our APA president, Dr. Vivian Pinder. She's actually taken on the Social Determinants of Mental Health as her presidential platform and really elevating this conversation to the forefront. She's also developed the Social Determinants of Mental Health Task Force. So thank you, Dr. Pinder. I'd also like to thank our CEO and medical director, Dr. Saul Levin, who provides continual support in these efforts and initiatives to move mental health equity forward. I would also like to thank the APA Board of Trustees, council members, assembly, caucuses, and administration for their continuous work and support in advancing mental health equity. And at this point, I'll hand the virtual mic over to Dr. Mario Sims. Dr. Sims, welcome. Thank you very much, Dr. James. You all can see my screen, right, in presentation mode? Yes. Okay, thanks. So first, I just want to thank you for the opportunity, thank Dr. James, as well as Gabriel, for the opportunity to talk about my work on social determinants of health. And I'm going to talk to you about some of the work that I've done in the social and psychosocial realm of cardiovascular disease health, and then also go into some other factors as far as general health. But I have no industry relationships to disclose. And so an overview of the presentation is that we'll talk about first the framework on social determinants of health, some of which was mentioned by Dr. James. Then I'll go into a little bit about the historical context of social determinants of health and how it gave birth to what we know as social epidemiology. And then I'll talk about some of my research on four domains of social determinants of health from a multi-layered, multi-factorial approach. And then talk about some social determinants of mental health, some implications, and then we'll go on to conclude about regarding approaches moving forward. Okay, so this slide, it's essentially, it just gives you a pictorial of the social-ecological model. It's a dynamic framework for analyzing social and spatial variation in health and disease. As you can see from the very robust model, it's, or Venn diagram, it goes from the individual to the public policy level. And so it helps us to contextualize the many layers that are involved in impacting one's life, be it health, be it educational, be it economically, et cetera. And so my research fits within this framework of social determinants of cardiovascular disease. So we go from the individual to the interpersonal, social relationships, et cetera, organizational, community, where you live, the context, as well as a macro level, and that's the public policy level. And so we know that Dr. James has defined what social determinants are, which are conditions in which people are born, grow, live, work, and age. And these circumstances are largely shaped by the distribution of money, power, and resources at varying levels, be they local, national, global. And so the social determinants of health are very pivotal to us understanding people's lives, as far as their wellbeing, from an individual level perspective, as far as, as well as a community level's perspective of wellbeing. And so examples include quality of education, affordable housing, poverty, exposure to crime, clean water, social norms, perceptions, and experiences of discrimination, just to name a few. So this figure shows the World Health Organization social determinants of health model, which displays the impact of socioeconomic and political structures, which are governance, policy, on socioeconomic position, things such as education, income, which impact downstream material circumstances, and then psychosocial and behavioral factors, which manifest into health equity and wellbeing. So a very comprehensive approach. And I think it unpacks a little bit more than the SEM model, socioecological model. And so a lot of my work has focused on the path between socioeconomic position and health equities. In current research, I'm starting to look at more upstream factors that impact health inequities. So in the 19th century, scholars drew attention to the increased risk of disease among the poor. And so the focus of public, in the field of public health, and so the focus of this field included social determinants as far as factors such as access to better housing, work environments, child labor laws, child maltreatment, sanitation, nutrition, access to immunization. And in his seminal study, W.E.B. Du Bois examined African-Americans who were recent migrants from the South into the Philadelphia metropolitan area during the turn of the last century. And so he studied the impact of social and environmental factors on infectious, largely infectious diseases among Black people. And so he found that poverty, low income, race were highly correlated with prevalent and incident infectious diseases. So we still see these patterns today, except largely for chronic diseases, physical health as well as mental health conditions. So therein were the seeds of epidemiology planted and thus grew from this work. And so we know that the central question has always been how social conditions give rise to patterns of health and disease. So this slide shows the intersection between social determinants of health and cardiovascular disease risk factors. The top maps show the geographic distribution of these risk factors that we're well of, prominent risk factors, obesity, diabetes, heart disease, cancer. And the bottom maps show the geographic distribution of social determinants. Less education, unemployment, poverty, Black population. And so we see that areas with high poverty have high areas of heart disease. And so clearly African-Americans are likely to live in the high poverty areas with high concentrations of poorly educated people who are unemployed, where there are also higher rates of illness in these risk factors, heart disease, cancer, et cetera. And that non-African-Americans are more likely to live in non-poverty areas where there are lower rates of these disease outcomes. So there's a need to understand the multiplicity of socioeconomic and psychosocial factors that impact health inequities. And so I've largely published social determinants work using the Jackson Heart Study, which is a single site prospective cohort study of African-Americans who reside in Jackson, Mississippi metropolitan area. And it's funded by the National Institutes of Health Heart, Lung, and Blood Institute, as well as the National Institute of Minority Health and Health Disparities. And so what I want to do is also bring to your attention the inventory of social determinants of health data that we've collected in the Jackson Heart Study. And these are largely proximate risk factors on the pathway between exposure and chronic disease, right? So you can look at them in numerous ways. Some are also looked at as potential confounders in various estimates or analyses to understand estimates of health inequity. So we have the domains of socioeconomic position, education, occupation, for example, psychosocial risk factors, depressive symptoms, for example, global stress, the realm of perceived discrimination, a very important one where we can look at everyday lifetime and the burden of that discrimination. What is it attributed to? How do you cope with it? Also neighborhood environment as another domain, social determinants. What does the neighborhood look like? The built environment, the degree of segregation, concentration of affluence or poverty. Also positive psychosocial factors, which we term resilience factors or markers for resilience, as well as resource measures such as optimism, social support, and networks. So I'll now briefly review some of our scientific work in each of these four domains. The domain of discrimination, socioeconomic factors, psychosocial risk factors, and then positive well-being. And regarding risk factors, we need to examine multiple dimensions of social determinants of health to understand inequities, really what I call in real time. How they impact people's lives at the same time, simultaneously, over the life course and at multiple levels. That's very, very important. So this slide just shows a sample of our work that's published on perceived reports of racial discrimination and cardiovascular disease risk factors and cardiovascular risk. And so our work has found that discrimination is positively associated with cardiovascular disease risks and other phenotypes such as hypertension, subclinical disease, as well as behaviors such as sleep, smoking, and obesity. So we've shown that there are multiple dimensions of discrimination, which are important in considering not only physical health disparities, but also mental health disparities. Okay. This slide gives a sample of our work we published on the impacts of socioeconomic status as a marker for social determinants on risk and incidence of CBD. So we found that participants high levels of education and income have lower prevalence of these chronic conditions, which we know, but it hasn't been shown in large cohorts of African Americans as our study has done. So basically, we found that SES is a protective factor against risk factors for heart disease. In our sample, this just gives a sample of our work published on the impact of psychosocial risk factors, and we say have on cardiovascular disease risk factors as well as CBD incidence. We found that psychosocial risk factors such as perceived anger, stress, depression, symptomatology are associated with increased blood pressure progression, reduced hours of sleep, and increased smoking and a risk of stroke. And finally, the fourth domain, this slide shows a sample of our work that examines psychosocial resources and cardiovascular disease risk factors. We hypothesize that it has a protective effect on these health conditions. And so we have found that having greater social support and social networks was associated with lower incidence of type 2 diabetes among men and women, and that higher optimism was protective against all-cause mortality. And so just a few notes on social determinants of mental health. Some mental health researchers have also examined proximate risk factors on varying mental health outcomes, and this is very important. But they've also examined macro-level approaches. If you remember in the social determinants of health model, the macro-level approaches were more upstream, and so certain research has found that income inequality is associated with depression prevalence, adverse early life experiences, domestic violence, parental divorce, et cetera, are related to suicide attempts. And among mothers with food insecurity versus those who are food secure, major depression and anxiety disorder are higher, as well as racial discrimination associated with major depression, as well as PTSD. And so this approach, it helps us to realize that social factors upstream must be addressed to address adverse physical, as well as mental health conditions. And the same must occur across other dimensions or disciplines of research. And so solutions having included interventions to look at and address social determinants of health, for example, the Nurse-Family Partnership program, which is an innovative early childhood intervention where nurses made home visits to low-income, first-time mothers until babies were born. They provided child care, addressed economic well-being. In other words, this was a comprehensive approach, and this approach helped to significantly reduce the incidence of child abuse, criminal activity of mothers, and dependence on social welfare programs. So evidence-based solutions are needed to consider the social inequities people confront in order to address proximate issues. So we need to consider upstream approaches, policy, structural, institutional levels must be considered to address root causes of social determinants of physical and mental health. Health-promoting policies must be considered that change social norms, that help society change the way it feels about inequality and inequity, and that it hurts everybody. It's not just one group. It hurts the whole. So policies need to be evaluated based on their mental and physical health impact. What level of impact do they have on these outcomes, upstream types of policies and governance? And so as a recent past chair of American Heart Association Social Determinants of Health Committee, I served as a co-author on the following policy-related position paper of the American Heart Association called Call to Action Structural Racism as a Fundamental Driver of Health Disparities. So the objective of this research review was to review the historical context, current context, and potential solutions to address structural racism in the U.S. And so some of our major findings included, asserted that future policies must be put in place and enforced that dismantle residential segregation and its negative economic, educational, employment, environmental, mental, as well as physical health consequences that ultimately impact downstream physical and mental health outcomes. Okay. And so also the dismantling of structural racism is predicated on understanding race as transforming attitudes about it, a little bit what I mentioned above. So we need to foster what is called allyship between racial and ethnic groups. And social norms need to change and people's beliefs about equal opportunity would change. And so as awareness would foster changes in cultural beliefs, attitudes, as well as political support and policy changes will follow as well, okay? So just to sum up, when we're considering social determinants of health models, we have to consider what portions of the model we're testing to be specific. And I think this reveals where to target intervention and prevention efforts. And my work has shown that there are multiple dimensions of social determinants of health that are critical risk factors for these health inequities, both psychosocial risks, as well as protective psychosocial resources. But it's, and these are novel perspectives. A lot of this has not been done to look at the intersectionality of these factors, as well as their independent and main effects on health outcomes. But there are knowledge gaps that exist in the literature. Number three, mental health research has also focused on examining social determinants as risk factors. But both of these levels, excuse me, these disciplines have a great understanding that we need to look at approaches need to be examined to help mitigate negative health effects of social determinants while intervening in the upstream continuum of the social determinants of health model. That is at the policy, structural and governance levels in order to accomplish health equity. So I'll leave you with this quote from W.E.B. Du Bois. Says, broadly speaking, the Negroes as a class dwell in the most unhelpful parts of the city and in the worst houses. The part of the population having a large degree of poverty and social degradation is usually found in the worst portions of our great cities. And it speaks to the topic that I briefly discussed with you today. And as you can see that things have really, haven't really changed much. Some, but by and large, there's still a negative effects of social determinants on health, mental and physical for marginalized groups. So there are broader structural, as well as macro, micro level issues at work that contribute to physical and mental health inequities. And it's clear that not much has changed for marginalized groups since W.E.B. Du Bois published this back in 1899. Thank you. Thank you. Okay, so thank you, Dr. Sims, for providing that foundation, that backdrop for us to now be able to look deeper into how these social factors impact mental health. So now I invite to the virtual microphone, Dr. Michael Compton to reflect and to provide his viewpoint on this topic. Dr. Compton. Thank you, Dr. James. I think we might be waiting for your picture. Okay, here we go. Thank you. I want to thank Dr. James, Dr. Pender, Dr. Levin and also Dr. Sims for a great overview. Dr. Sims started with a really wonderful overview of the social ecological model. And he gave us some definitions of the social determinants of health. And I guess I'd like to start by giving another very similar definition of the social determinants of mental health in particular. The social determinants of mental health are societal problems that set the stage for at least four mental health related issues. First, they impede the achievement of optimal mental health and wellbeing in the population. Second, they increase risk for and prevalence of mental illnesses and substance use disorders in the population. Third, among the subpopulation with an existing behavioral health disorder, that is our patients, the social determinants worsen course and outcomes. And fourth, the social determinants also create health disparities and health inequities. So the social determinants framework is a population level concept. As such, the social determinants must be addressed primarily at the population level. This is really accomplished in two ways. One is by changing public policies, which are laws, for example. And another is by changing social norms, meaning biases and the various forms of discrimination. And I'll come back to this concept of changing both public policies and social norms a bit later. Dr. Sims laid out four domains of social determinants and how his research on cardiovascular disease has addressed each of those domains. Those domains were perceived discrimination, social factors, psychosocial risk factors, and positive psychological wellbeing. I've also written about four domains of social determinants of mental health, each of which includes four types of social determinants for a total of 16 social determinants that I would like to briefly list for you. The first domain includes those that we could characterize as pervasive, highly detrimental U.S. problems. One is adverse childhood experiences. Another is discrimination and related social exclusion and social isolation. Another is exposure to conflict, violence, shootings, war, and finally, involvement with the criminal justice system. A second domain of social determinants, which also includes four types, is related to low SES and limited opportunities to accrue wealth. So here we're talking about education, low educational attainment or poor quality education or educational inequalities. We're also talking here about employment, unemployment, underemployment, and job insecurity. And about income, poverty, income inequality, and wealth inequality. And finally, area level poverty and concentrated neighborhood poverty. The third domain of social determinants of mental health is related to basic needs. Needs in terms of housing, food, transportation, and healthcare. So in terms of housing, we're talking about homelessness, but also poor housing quality and housing instability. With regard to food, we're talking about food insecurity and poor dietary quality. And I'm gonna come back to food insecurity in just a minute. And poor or unequal access to transportation. And finally, being uninsured, underinsured, or having poor access to healthcare. And then the fourth domain of social determinants of mental health are those related to both the immediate and the global physical environment. This is the public health concept of adverse features of the built environment. Also characteristics of neighborhoods, neighborhood disorder, disarray, disconnection. We're also talking here about exposure to pollution, whether it's in the air, water, soil, or even noise pollution. And finally, we're talking about exposure to the impacts of global climate change. I'd like to spend just a couple of minutes focusing on food insecurity as a social determinant of mental health, which I'm particularly interested in, and which I think has largely been neglected by our profession. In 2020, the prevalence of food insecurity in the US was 10.5%, according to the USDA, which conducts a large-scale national survey each year. And 10.5% equates to 13.8 million US households. Now for households with children, the figure is even higher. Rather than 10.5%, it's 14.8%. In our country, where we have more than enough food to go around, but in which access to nutritious food is unevenly distributed, food insecurity of this magnitude is a market failure. It's a policy failure. It's a societal failure. Also in our country, food insecurity is associated not with underweight or malnutrition, as it would be in low-income countries, but rather with overweight and obesity. This is because limited food dollars are usually spent to buy the most calories possible, which equates to junk food, fast food, other types of highly processed, high-calorie and low-nutrient foods. Now, food insecurity has been repeatedly linked to poor mental health and psychological distress. I was able to find 26 studies involving large-scale, nationally representative surveys. Additionally, there are 19 studies in English involving infants, children, and elementary school kids, 15 studies involving adolescents and middle school kids, 12 studies involving college students. In all of these studies, food insecurity is always associated with poor mental health indicators. Food insecurity is also associated with an increased prevalence of mental illnesses like depression across the lifespan and also substance use disorders. I found 58 studies on food insecurity and depression or suicidality in adults, and another 54 studies specifically involving pregnant women, postpartum women, or mothers. Now, most of this research is actually published in the public health and nutrition journals rather than in our psychiatric journals. Finally, with regard to food insecurity, I want to mention that there's a growing body of research suggesting that among individuals with serious mental illnesses, there's a very high rate of food insecurity. In 2013, Mangurian and colleagues did a study of patients with SMI in San Diego, and they found that 71% of patients in the mental health clinics were food insecure as opposed to that 10.5 national figure. I did a study involving 300 patients with serious mental illnesses in five different community mental health clinics in Washington, DC, and similarly found that 69% were food insecure. Obviously, being food insecure impedes medication adherence, clinic attendance, and illness self-management. But back now to my reflections on Dr. Sim's presentation. I agree with Dr. Sim's that both perceived discrimination and subjective social status are major social determinants underpinning health inequities in cardiovascular disease. Like Dr. Sim's findings with regard to heart disease, my own research has shown that among people with serious mental illnesses, both perceived discrimination and subjective social status increase depressive symptoms and diminish at least two key facets of recovery, hope and empowerment. Furthermore, with regard to comorbid substance use among individuals with SMI, we found that whereas objective social status using measures of income and education was associated with cigarette smoking, subjective social status was associated with drug use severity. So both matter. Finally, to wrap up, I also completely agree with Dr. Sim's that upstream approaches, meaning at the policy level, are how we must address both these root causes of cardiovascular disease and these root causes of mental illnesses and substance use disorders. This means our involvement in policy change, like education policy, like income-related policies, such as minimum wage legislation and the child tax credit law, policy change pertaining to the environment and climate change-related policy, policy change around housing, policy change around urban planning, policy change around food and farming policy, which means the Farm Bill. The bottom line is mental health in all policies. And as Dr. Sims also noted, not only do we change public policies that underpin the various social determinants, but we also must change social norms. That's how segments of the population feel and think about others and behave toward others. Social norms are about biases, stereotypes, stigma, racism, sexism, and discrimination based on race, sex, and other innate or adopted characteristics. So we all, as psychiatrists, have a role not only in pitching in to change public policies, but also in changing social norms. We must address both. Social norms drive public policies and public policies drive social norms. This is exactly what Dr. Sims has referred to as intervening upstream. So I'll stop here, and I appreciate the opportunity to have been able to chime in. I think at this point, Dr. James will turn it over to Dr. Bloomberg-Jernigan. Thank you. Absolutely. Thank you so much, Dr. Compton. That was a nice integration of sort of the backdrop provided by Dr. Sims, and of course, your work in this area over the years that has also shed some light on what we need to do and how we need to approach it and what's important. We will take questions after Dr. Jernigan provides her reflection in reference to the initial presentation. So just hold tight, and we'll get to that very soon. So I'd like to, again, give the virtual mic to Dr. Jernigan. Thank you, Dr. James. And I wanna say thank you to Dr. Sims for that overview, which was very comprehensive and pretty painful to see that not a lot has actually changed over time. And thanks to Dr. Compton for that really comprehensive response and emphasis on food insecurity work. That's a really nice segue into my work, which focuses on, a lot of it focuses on food insecurity. So I'm indigenous. I'm Choctaw from Oklahoma, and I come from the southeastern part of Oklahoma, where I've lived my life. And I am an intervention scientist. And I work in native communities where it's very common for us to not necessarily choose our career based on what we'd love to do or our visions for ourselves, but really in many ways, in response to what the community needs are. And at the time that I was going through school, diabetes was the biggest need in our community. We have extraordinarily high rates of diabetes. Pretty much everyone in my family had it. And so that was the focus of my work was diabetes self-management specifically, was my dissertation research. And once I got out into the community to do sort of my own research initially with small funding grants, I pretty quickly realized that I could continue running diabetes trials in the way that I had been trained, but I was not going to be able to engage community members where they were, which was and is a tenant of community-based participatory research. And I'm a participatory researcher and an interventionist. So one of the first studies that I ran was with diabetes funding, and it was with a community partnership in California. And I came into the community with money from a funding agency to do diabetes work. And the community told us that that really wasn't their focus, that they had other major problems. And the problems that they identified were probably of the nature that Dr. Sims would be very interested in and others with different types of expertise than I had. Their main struggle was racism. And specifically they had on their reservation a lot of violence with the neighboring non-native community. And that was their number one priority. And so they said, we'd love to partner with you, but if you're really a participatory researcher, this is what we want to work on. And so I had to figure out very, very early on in my career how I was going to figure out how to address community needs with funding that was very disease-specific. The project ended up being focused on how racism was manifesting itself in food access and food insecurity. This population was like most, virtually all native people in the United States, removed from their traditional lands, restricted to reservations, and had very, very limited access to healthy food, extremely high rates of food insecurity. Racism was shown in the local grocery store where the owner of the store, a white resident of the area, upcharged all the foods knowing that the native people didn't have transportation on and off the reservation, which was in mountainous area. And so that was one way that we directly addressed racism. How do we lower the costs of food? How do we engage with local producers, farmers in the area? What do we need to change food options from the local commodity trucks that were there? Could we get a refrigerated truck? So my intervention work was very pragmatic and it was around local needs. And it went from the way I had been trained, which was very disease-specific, to working in direct response to the community. And it really went from there. Food insecurity is a very personal issue for me. I grew up on a reservation with food insecurity. We had commodity foods as a child. I went to bed hungry. So I definitely related to that issue and was a key reason that I studied it in my career. And I didn't set out to do social determinants of health work. I mean, we don't really conceptualize it like that. In native communities, everything is related and it's holistic. And so you don't really think of it like that. And so in the work, it's very easy to intervene on multiple levels, at structural levels, at policy levels, at environmental levels, which are all the areas where I focus because those are the levels where those social determinants manifest. So racism, inadequate housing, lack of food. Those are all parts of what make native people suffer disproportionately. And so those were naturally the areas that we've intervened on. I am able to take priorities like food insecurity and reconnection of traditional food practices, how they relate to CBD, how they relate to diabetes, how they relate to blood pressure and BMI and all of those risk factors that I was trained in in cardiovascular disease and write funding, for funding agencies like Dr. Sims mentioned NHLBI and intervene on those multiple factors. The studies that I've implemented have been focused on healthy retail interventions. So getting healthy food to very rural remote reservation areas. Dr. Compton referenced the food insecurity rates at the national level fluctuate between 10 and maybe 14%. Our studies show that food insecurity in rural communities is at least three times that. The rates were 52% in my own tribe, Choctaw. So as the community members say, food insecurity is not a problem that's been solved in rural reservations. And intervening through the healthy retail interventions, getting food to be distributed through the different vendors and distribution centers multiple times per week, as opposed to one time per week keeps the food fresh and creates better access. And that in turn has a positive impact on blood pressure, BMI, A1C levels for diabetics. We've done farm to school interventions with children very young, and that has a positive impact on families and their health outcomes. It's only been really recently that I've started to think about the role of mental health more directly in our work because of the requests of the community members asking for this specifically. There's a lot of interest on trauma. There's a lot of interest on how that relates to food practices and the types of work that Dr. Sims references. Blood pressure, how those experiences have impacted our communities. And it's been very positive to engage mental health professionals with us so that we can look at food insecurity and depression and some of the variables that we continue to research. How do they impact families? So I think those are all of the issues that I've been working on directly as an interventionist. And I think one last thing I'll say, because I really wanna hear the questions of the audience, is that within indigenous communities, the focus of restoration of traditional practice, restoration of land-based initiatives tend to do the kinds of things that mainstream culturally adapted interventions like a diabetes prevention program or a general healthy retail intervention aren't able to do because that's so central to our culture. And so those are the things that with indigenous communities, we are looking for indigenous models of health, which naturally include mental health. And so our field as a whole is moving toward use of indigenous models of health instead of the other types of models of health and behavior change that have been traditionally used in these public health interventions. And there's such a paucity of those in the public health and medicine literature that that's been a real focus is, how do we take indigenous ways of knowing and indigenous practices and put them into our public health interventions, which naturally include ways to integrate mental health supports with the other aspects. So disease. So those are the areas that I focus on and really welcome questions. Thank you. Thank you so much, Dr. Jernigan. Really, really appreciate your perspective and the lens that you bring to this conversation. So now we're going to open it up for questions. And I actually have one that came in I'm sorry, I actually have a question that came in. And first of all, let me thank all of you. Wonderful presentations. I liked the interdisciplinary approach that you all brought from medical, sociological, epidemiological, public health. And I think that really sort of encourages us to think creatively about how to address this problem of social determinants of mental health or social determinants of health in a mental health arena. So the first question that I actually received was despite the spotlight on the importance of social needs, there's little consensus about the responsibility for addressing social needs or the best approach to the problem. So we've heard the research. We know that it exists. We've known that it existed for a while. And so, but there's not really a consensus on how to address it, particularly in the clinical arena. Would anyone like to try to address that question? I'll open it up. Well, I would say that the first step toward addressing social needs among our patients would be to screen for social needs in a systematic way. And so even though as psychiatrists, we do a good job at screening for homelessness, do we do a good job at screening for housing instability? Even though we do a pretty good job at screening for unemployment, do we screen for job insecurity? That very uncomfortable sensation, chronic stress around the fact that you might not have a job at the end of the month. Do we ask our patients about that? Are we screening for food insecurity? If not, we should call up our primary care and pediatric colleagues because they are screening for food insecurity using validated one or two item screeners. So I would just say that the first step is to screen in terms of social needs among our patients in the clinical setting. Obviously, we've all talked about the broader intervention, which is policy change. Exactly, thank you very much. Any other additional comments? Sure, well, I think that, and I totally agree with Dr. Compton as far as screening for, but also taking a step back is having a systematic way to define varying social determinants. How do we define it? Is there a standardized approach? Do we have a consensus understanding of what they are across the board in varying domains, be it stress, be it discrimination in screening for, so that it can be more of a comprehensive, taking more of a comprehensive approach to treatment from a clinical perspective, but also, so just defining what we mean by these factors so we can adequately address them. And that means across multiple ethnic and racial groups. Does it mean the same thing in one group as it means in another? I think Dr. Jernigan did a great job at talking about that approach among native peoples, coming up with their own skills and models and definitions. Because I think that one size doesn't fit all. So I think just those definitions are very important. Okay. And I would add also that as Dr. Compton mentioned, there are a number of screening tools for social determinants of health that are out. And as you mentioned, talk to your colleagues in primary care, whether it's pediatrics, internal medicine, et cetera. So, given the significance and the importance of social factors that impact mental health, what is it that you would suggest that we do to really, I don't know, push the envelope in terms of really implementing utilization of these current tools that are being tested in various healthcare organizations like CMS has its own model, et cetera. How can we make this more of a commonality in the mental health arena? You think conversations like this, I mean, what do we need to really do to push that? I mean, because I think we all know that there are social factors that impact health. We all know that we need to, I mean, we know it, but I don't know what we're doing about it. But we know that there are these various social factors we need to impact, policy, et cetera. But the practicing psychiatrists who seeing patients every day, what can they do to begin to bridge the gap between these social needs and these mental health outcomes? I guess I would think back to history a bit, and that is among the 16 social determinants that I listed, the one that we as psychiatrists are most familiar with perhaps is adverse childhood experiences. And the reason we're so familiar with that is in part due to the hallmark research that was done out at Kaiser Permanente a decade or two ago. And now the whole field of medicine is very much interested in ACEs, adverse childhood experiences. They're screened for. We've created an approach called trauma-informed care. So if we can do it for one social determinant, albeit much more work needs to be done around the ACEs, we can do it for the others. And so I think it's having these types of conversations, not just around social determinants as an umbrella concept, but individual social determinants. This conversation has leaned toward food insecurity, which I was happy for, a bit unplanned, but we could have these conversations around specific social determinants to try to move those specific needles. Okay, thank you. I do see a comment in a chat, let's see, William Lawson, wonderful discussion, but little about the interaction of genetics and social factors. I had done work looking at genetics impacting taste preference in diabetes and found that food preferences impacted cultural dietary preferences, thoughts from the panelists. And just by the way, this is a series around social determinants. And just of note, I'm glad you asked that question. We are going to have a session specifically focused on genetics, genomics, and the impact as well. So hopefully you can join us for our next webinar, where we'll get much deeper into that. But I open the question up if any of the panelists would like to address that question. Well, I'm not a geneticist, but I may have served as a co-author on several gene by environment papers looking at the intersection of psychosocial factors and their associations and correlations with multiple SNPs for varying diseases, be it lipids, blood pressure, diabetes. And what we're starting to look at is taking a more of a mechanistic approach, starting to look at exposures to psychosocial stressors on the pathway of that exposure to the outcome, how metabolomics and some proteomics serve as mechanistic pathways in explaining some downstream diseases or chronic illnesses. So I'm starting to get more into that. I don't know, maybe the other panelists can talk a little bit more specific to the question. We know from our work that cultural factors highly influence child food preferences. And it used to be thought that that maybe started at an early age, and now we know it starts in utero. And epigenetics has shown that it may even be earlier than that. So I think this is an example of if you are not, if you don't have access to healthy foods, it is very unlikely that your children are going to have taste preferences that support healthful eating because they are not exposed to it either. And they definitely weren't exposed to it in utero. And those are just parts of how this sort of, goes across the generations. One of our studies looked, there's a willingness to try and measure, and it's related to what your parents eat at home and children who are exposed early on to fruits and vegetables are much more willing to try. There's a lot of research around that area. I wanted to say too, though, with regards to the other question that I'm not a practicing psychiatrist, but I know that I think Dr. Sim's work is an example of what I think is incredible, powerful work on the front of racism and its impact on health. We didn't even use that word in school. We weren't encouraged to say racism has an impact on health because it couldn't be measured. And people were doing those studies. And now that we're able to show those things through this kind of work, we're able to be able to state it and to intervene upon it. And that wasn't like that even 20 years ago. It wasn't like that even 10 years ago. So I think that this is changing the face of public health. And I would push us to be very honest in our study sections. Do we need another study that's offering health education, that's offering one level of intervention? If these interventions are not addressing the social determinants of health, are they really gonna push the field? If the answer is no, we don't need to sink millions of dollars into yet another intervention that's a replication of something we already know well. Okay, thank you. Thank you very much. Next question. It says, thank you, panelists. Really excited for indigenous ways of knowing about mental health. Dr. Jernigan, what are your thoughts on culture as cure for diverse tribal communities? Are we seeing a transition with more American Indian Alaska native healthcare leaders? Hello from psychiatry residency in North Dakota, ancestral and current home of multiple tribal nations. Culture as cure is the direction of indigenous health, absolutely. I think the restoration of traditional practices does so much to address all that has been done. And so when you hear that epigenetics is a thing and you know that that is the way that you were raised and you understood seven generations or you understood that everything that your ancestors did has an impact on you. The validation that you get of saying, oh, we were told that was just a nice folklore. No, it's actually real. We are scientists and our work is pragmatic, developed over hundreds of thousands of years. And so I think valuing community knowledge, valuing lay knowledge is really the direction that a lot of these interventionists are going and especially in native communities. Yeah, thank you very much. I know that we are slightly over time and I really want to be cognizant and respectful of everyone's time. I could sit here and listen to you all talk for the rest of the evening but I know you have lives past this. So I do want to take this opportunity to say, thank you so much for taking the time to really start this conversation about social determinants of mental health, the background, the history, looking at cultural aspects. What do we need to think about moving forward? The focus on food insecurity, the policy issues and questions and concerns. I really think, and I'm really hoping that it's stirring some additional questions as people begin to think about what can they do in their spaces and their places about moving this agenda of closing the gap between social factors and mental health outcomes. That's really my hope and my goal. Again, I mentioned this is a series of webinars. So our next one, I believe is March 16th and it will actually focus on the role of genomics in ameliorating health inequities. So I hope that you take time to join us again as we continue this conversation around social determinants of mental health. Again, thank you all, I really appreciate it and thank you for those who joined us in the virtual world on Zoom and have a good evening, good night. Good night.

social determinants of health

mental health outcomes

discrimination

socioeconomic status

psychosocial risk factors

positive psychological well-being

systematic screening

comprehensive approach

culture

indigenous communities