Good evening and welcome, everyone, to the American Psychiatric Association's Looking Beyond webinar series. This webinar is actually an opportunity to learn about approaches or ways to address mental health inequities through an interdisciplinary lens. My name is Dr. Regina James, and I'm the Deputy Medical Director and Chief for the Division of Diversity and Health Equity here at the APA. And before we get started, I want to first take this opportunity to thank a number of folks. The APA President, Dr. Rebecca Rundell, our CEO and Medical Director, Dr. Saul Levin, the APA Board of Trustees, Councils, Assembly, Caucuses, and Administration for their continuous support in advancing mental health equity. And in honor of Black History Month, I also wanted to pay homage to the many black psychiatrists who have made significant contributions to advancing our understanding and providing services to those in need of mental health care. And let me just highlight a few firsts, just a few select firsts, just, again, in honor of Black History Month. Dr. Solomon Carter-Fuller, the first black psychiatrist and one who has made significant contributions in our understanding of Alzheimer's disease. The first black President of the APA, Dr. Altha Stewart. The first black woman President of the American Medical Association, Dr. Patrice Harris. And the first Director of the Office of Minority and National Affairs, which is now the Division of Diversity and Health Equity, Dr. Jean Spurlock. Again, so in recognition of Black History Month, just wanted to highlight those first and all psychiatrists who serve those who are medically underserved and marginalized and minoritized populations. So moving forward, today our topic of discussion is clinical bias and disparities in mental health treatment continuum. And to set the stage for the webinar, I'd like to pass the virtual mic over to my colleague, Dr. Bernard Ng. But before I pass him the mic, let me first share a little bit about him. As a psychiatrist and researcher, he is the Founder and Executive Director of Sun Valley Behavioral Health. He has published extensively in diversity issues, Latino mental health, telepsychiatry, neurocognitive disorders, and social determinants of health. He was the Chair of the Council of International Psychiatry of the American Psychiatric Association. He was the President of the American Society of Hispanic Psychiatry and the President of the Mexican Psychiatric Association and the Representative for Zone 2 of the World Psychiatric Association. I present to you Dr. Ng, who will introduce the panelists and moderate the session. Thank you so much for joining us, Dr. Ng. Thank you very much, Dr. James, and thank you all for being connected today. I'm very honored to be distinguished with the responsibility of presenting our excellent speakers today and also to moderate this session. Very thankful also to APA for paying attention to these very important topics. And today, as it was already mentioned, we're going to be talking about bias in clinical practice, which is a persistent cause of healthcare disparities compounding the vulnerabilities of historically excluded populations, such as those comprising minority ethnic populations, the poor, low health literacy individuals, sexual minorities, children, women, the elderly, the mentally ill, the overweight, and the disabled. Implicit or unconscious provider biases impact the mental health treatment continuum at various stages. And to talk about those stages and the different possible approaches, we have a team of three excellent experts in this topic that I'll present at this moment, and they'll be coming one by one presenting their topics. But even more important than that, the nature of this program is that those of you guys connected on the other side of the computer send their questions so we can convert this hopefully in a very live dialogue. So we're going to have with us Dr. Michelle Durham, who is a board-certified physician in pediatric psychiatry, adult psychiatry, and addiction medicine. She's the Chief Behavioral Health Officer for IBM Sino Foundation, where she's leading the expansion of outpatient and integrated mental health services. Her public health and clinical roles have always been in marginalized communities, with a focus on health equity and advocacy for equitable mental health treatment. We're also going to have Dr. John G. Takeshita, who is the Associate Chair for Clinical Services at the John A. Burns School of Medicine of the University of Hawaii, where he is the Director of Medical Education and Patient Care Services for Consultation Liaison Psychiatry and the Director for the Geriatric Psychiatry Program. And last but not least, we're going to have Dr. Carmen Black. Dr. Carmen Black is a proud Black American woman descended from enslaved persons and is the Assistant Professor of Psychiatry at Yale University School, excuse me, at Yale School of Medicine and the Director of the Social Justice and Health Equity Curriculum for Yale Psychiatry. Dr. Black's educational and publication expertise emphasizes how providers' own racial prejudice and bias against persons living with mental illness can heterogenically harm patients during real-time clinical practice and or exacerbate behavioral emergencies. Well, let's get this going, and I pass on the virtual microphone to Dr. Durham. Thank you for joining us. Thank you, Dr. Ng, for that warm welcome and to this, not only to this talk today, but for introducing me. I'm really happy to be with the rest of my esteemed colleagues to talk a bit today about bias and mental health inequities and thinking about how our own biases to discrimination and particularly racism really impacts the care we give patients. My overview is going to be very condensed. I think we each have a little bit of time, but I also want to set the frame that the APA Foundation, there are many tools and webinars that we have on the website that can be accessed to really fill in maybe some of the gaps in this brief one-hour presentation today, but that we've done a lot of work, I think, as an organization in making sure all of us are well-versed on these topics, start doing some of the work ourselves, and having a lot of other references beyond what we're going to discuss today. I'm going to dive right into thinking a bit about child mental health and show you some pretty startling statistics, I think, of over decades of research that we know of how kids and families are impacted by bias and discrimination and racism and systems that don't allow them to get the care they need and deserve. Next slide. When I think about factors that contribute to underdiagnosis or misdiagnosis, we're thinking about a lot, at least in probably all of our work, but I'm focusing on child mental health, I'm thinking about there's a symptom, there's something that's going on for this kid. There's a lot of stigma and treatment delays, especially for Black people and other communities of color, and how much is rooted in community, but also how much is rooted in systems that don't allow folks to receive care in ways that are relevant to their own culture, to their experience, to who they are. Then within that, we have to also think about our roles as clinicians and the bias that we bring to the table when people do present. Next slide. I'm going to go over in a few slides in my brief time with you a little bit about just thinking about just some stats and what we've known and what we continue to know, and how we all need to really improve this burden, unfortunately, that kids and families are having when they want to engage in treatment that they're not really seen as people needing treatment at times. Some studies have suggested that Black children and other children of color are over-diagnosed with neurodevelopmental disorders and disabilities and are disproportionately represented in special education. Parents and teachers may differ in their perspectives regarding their experience with and knowledge of appropriate expectations of child behavior at given developmental levels. We see this often of parents feeling from different backgrounds, from different groups, that their child is developing normally and that it's a problem within the school or with the teacher. Last but not least, Black youth may express their depression symptoms differently than white youth, including through externalizing behaviors. This is something we see time and time and time again. What we have to screen and assess is missing folks. Some of this of what I'm presenting today, which I encourage a lot of folks to read, is Ring the Alarm, the Crisis of Black Youth Suicide in America. It's a report by the Congressional Black Caucus that came out in 2020 that I really encourage. It's pretty profound, the way that we're missing kids and youth of color in screening for depression and for suicidality. Next slide. Part of that report, it showed that Black youth dealing with mental health issues are more likely to refer to inpatient services than white youth or are often pushed into the juvenile justice system where access to adequate treatment is even less available. We also know that compared to their white counterparts, Black adolescents are significantly less likely to receive care for depression, which we know is a contributor at many times for suicidality. Not the only thing that causes it, but a significant risk factor. Next slide. When we think about, again, underdiagnosis or misdiagnosis, youth and caregiver valid mistrust of mental health professionals can delay or prevent care. Black people on average also receive poor quality of care when they actually pursue mental health treatment. We know that our assessment tools really lack nuance in anything culturally specific. It's really normed to white individuals, and so we don't really truly understand, and that's, I think, what leads a lot of times to either under or misdiagnosis of youth. One of those things that I think about a lot is oppositional defiant disorder. It's something that is a part of the DSM that we are looking at certain symptoms of youth, but really, I think if we take a step back and look at it from different perspectives, is this youth thinking about, is it depression? Is it anxiety? Is it trauma really exacerbating those symptoms? Then for many Black adolescents, exiting treatment early is the norm, and poor engagement is a key influence on termination, which is a huge factor in thinking about that person, that clinician in the room, and why are these Black youth exiting so quickly. Next slide. The next couple of slides give more specifics about thinking about us in the field. Psychiatrists, social workers, psychologists were more likely to assign a diagnosis to a non-Latinx white youth as compared to Black or Latinx youth. After controlling for age, gender, functional impairment, and prior service youth, Black youth in mental health services were less likely to be diagnosed with ADHD or any other type of mood disorder compared to white youth. When we still control for socioeconomic status, age, gender, and functional impairment, Black youth were more likely than white youth to be diagnosed with disruptive behaviors and conduct-related problems. Black youth, last but not least, are more frequently diagnosed by their clinicians with conduct disorder and other types of psychotic disorders, which many of us have heard time and time again in the adult population, but this is very true for young people as well. Next slide. When we think about psychiatric inpatient settings, Black male adolescents are more frequently diagnosed with schizophrenic spectrum disorders than their white counterparts. There's delays in diagnosis of autism for Black children, as they are less likely than white children to receive their diagnosis at their first specialty care visit. We know it's a critical time between the ages of zero and two to have a diagnosis of autism if it's going to be made. Prognosis is much better when you make the diagnosis early. Black children were more likely to be diagnosed with adjustment disorders and conduct disorder than to be diagnosed with ADHD. We often talk, and the media has probably done a good job of this, unfortunately, of talking a lot about the over-prescribing, the over-diagnosis of ADHD, but what we know is that for Black kids of color, this is typically not true. They are not getting that diagnosis. They're getting a lot of opposition or conduct diagnoses. Next slide. Prevalent studies show relatively few racial and ethnic difference in the patterns of disorders, but diagnosis in treatment settings seem to indicate more racial and ethnic inequities. We know that in prevalent studies as well, diagnosis in clinical settings where the criteria are less well-defined and vary across treatment settings indicate more differences. And then misdiagnosis by mental health professionals due to cultural biases, racism, or stereotypes may over- or underestimate pathology and impairment. There's a lot of errors in this diagnostic assessment in either direction. And so I think the one that I just pointed out about ADHD in particular, there is really an under-diagnosis in Black people and other youth of color when we think about that particular diagnosis. Next slide. And then once Black people and other people of color in care, they actually receive less information about their treatment. So the informed consent process isn't really there or is not adequate. They're more likely to be given inappropriate treatment referrals and recommendations for their presenting problems. They are misdiagnosed when they have the same presenting symptoms as White people. Next slide. So when I think about some strategies, and I know my colleagues will set the stage for other strategies at the individual level as well, I'm going to talk a little bit more globally. Next slide. About what we need to think about, and all of us have to participate in some advocacy work here in order to shift this. Next slide. When I think about it, I think about it from four different angles. Research. There's really a lack of cultural relevance of empirically supported approaches for any evidence around certain populations. And when we think about kids, kids of color, youth of color from many walks of life, we really don't have that culturally relevant supported research. We also need to all advocate for increased funding at NIH and all levels to study Black youth mental health and for investigators who want to study this. There are some articles out there which we can reference later too about just this notion that NIH typically doesn't fund a lot of community-based participatory research. Research that is invested in the community, with community maybe as a part of asking the questions and the relevant questions. How are we really going to get to some of the empirically supported approaches by different cultures if NIH and other big agencies aren't supporting that? Next slide. Access. How do we integrate mental health services into primary care? I talked a bit about youth and adults and families in general not being able to access care when they need it. Integrating mental health services to primary care is one approach. Thinking about how do we screen and assess earlier instead of waiting until people are in crisis and needing services? How do we think about barriers to access, like transportation, child care, families having multiple jobs and difficulty leaving work, and create more programs that are community focused in schools, in churches, or wherever folks are? Really bringing treatment to them. Advocacy for mental health parity and reimbursement of services for all insurance providers. I put this here specifically for all insurance, but I work a lot with folks who are on Medicaid or under or uninsured, and those reimbursements, and we can't get people in the field to want to work in those particular systems because the reimbursement rates are really so low for the work we do. In a mental health system weighed heavily toward white values and not created for Black people or people of color, then we really need to think about that and how do we, if we're going to really think about access and wanting people to engage in treatment, we have to shift how the system is made. There's a word cut off here, but also thinking about how in each of our areas and each of our establishments, thinking about a community accountability board. Who is going to keep us accountable for the work we're doing if it is so entrenched in bias, discrimination, and racism? Having community be a part of it is one step in that direction. Next slide. The workforce. We need to advocate, recruit, and retain a diverse workforce for the betterment of all folks who are ready to engage in treatment. We know that we're very much so lacking. I'm putting one statistic here. There are many from different backgrounds, but we know for the Asian community, Indian American community, many communities, the Latinx community, there is really a paucity of folks that they can go to who they identify at some level with, and we really need to work on this at all levels. Last but not least, thinking of the next slide, is around culture humility. While we're working on all of these other things that individually, we really need to take the time to understand what folks think about the diagnosis and treatment. What can they do based on the recommendations? Are we asking the right questions? Are we just throwing information at people or not giving them sufficient information and allowing them to have this conversation? Really, that patient-centered care that many of us talk about, but are we actually doing it? Both variations of the interpretation of behavior found not only among parents from different cultural backgrounds, but also among school personnel and healthcare providers. Each of us has to constantly reflect on what we're doing, how we approached it, was bias at play, and that might be working with our peers to figure that out together in team meetings and other groups. We have to collaborate and learn from each other for the best outcomes, ultimately, for the families we're working with. Now I'm going to pass the baton I think back to Dr. Ng for the next one. Yes, thank you, Dr. Jerome. And wow, we got going already, huh? Okay, pass on the microphone to Dr. Takeshita. Thank you very much, Dr. Ng. I'm gonna be talking about cultural issues in emergency psychiatry. And there's my email if people have any other questions. And also I'm the current, president of the American Association for Emergency Psychiatry. So I'm really gonna have this focus on how does culture affect presentation in the emergency room. If I could get next slide. So what's unique about the emergency psychiatry? I think what's unique is that it's the intersection of mental health and the police. And as the police officers always say to me, we have to decide who goes to the hospital, who goes to the law enforcement. And although there is some mental health screening, by and large, police make up quite a bit in terms of whether they go to the health side or the public safety side. The emergency room is where the social determinants of healthcare become real with issues about homelessness, poverty, substance intoxication, violence. This is routine in the emergency room setting. And because of issues of shame, mistrust, stigma, some patients may present with much more severe illness in much later presentation than those with less of these issues. So for instance, people may present only when there's danger, when their psychosis is still not in a dangerous situation. And unlike the outpatient side, there's really no choice in the selection of physician by the patient and vice versa. You get, the patient gets the doctor and the doctor gets the patient. And there's really not much choice in comparison to the outpatient side. Next slide. Just a few issues about definitions about racism and bias. So structural or institutional racism are those of systemic, much more laws of society that in previous era, housing discrimination was standard, it was common, and it was really at the societal level. And in terms of bias, we have explicit bias where the person has awareness that they're stereotyping or implicit bias, which is unconscious negative beliefs. So one's explicit, one is implicit. And there's a third concept called aversive racism that Dr. Black will be talking about a little bit later, which is a particular problem. These are individuals who have low explicit bias, but high implicit bias. So these are the individuals who'll say, well, I'm not racist at all, but they actually are. And what they do in terms of healthcare is particularly damaging. Next slide. So why is it such an important issue in emergency psychiatry? So implicit bias particularly happens when you're stressed or overloaded. And that unfortunately is what happens in the emergency room setting. You have no control over the number of patients, who comes in, it happens all hours of the day and night. The patients are coming in with dangerous behaviors. And the part that the data shows is the assessment of dangerousness often occurs on phenotype, meaning the appearance. As you know, the genotypes of all groups are very much essentially the same. But African-Americans have been perceived as more dangerous, more likely to be restrained compared with Caucasians. And how does this occur? A lot of it has to do with automatic thoughts, pattern recognition, which really enhances stereotype and racism. So the practitioner in the emergency room setting may just look at a person and decide, well, I'm gonna think about giving a medication, I'm gonna think about seclusion and or restraints, rather than really thinking about this individual. And there's been other studies looking at other variables related to hospitalization, age, gender, race, ethnicity, homelessness, all related to hospitalization. Next slide. Just wanna talk briefly about this term of excited delirium. This is very controversial. It involves an agitated state that can lead to unexpected death, typically in police custody, although it can also happen under some medical care, although the former is much more common. This is not really a diagnosis. It's really a term because this has been opposed by the American Medical Association. It is not part of any DSM nomenclature. And it's become a disproportionate labeling for young African-American men. So there was a paper in 2009 called the White Paper Report on Excited Delirium Syndrome. And this was created by the American College of Emergency Physicians. And a recent paper on this by Walsh and others showed that there was really excessive reliance on racial stereotypes with this concept and really enhanced that bias. Next slide. So what are some practical suggestions in the psychiatric emergency room setting? It's really important to look at the patient as an individual, establish a rapport, basically doing what a good clinician does. Be aware of bias and racial or cultural awareness versus stereotyping. There's a next line, which unfortunately is not visible, but what that is is that there's an implicit bias test that every practitioner should do. It is unfortunately a black versus white bias. So it doesn't look in terms of other groups, but it looks at whether you have a bias toward one group or another. And this was one study looking at medical students and most medical students had a bias toward Caucasians. Another caution is those with limited English proficiency and use of interpreters, because in those areas, again, you tend to look upon what you know or what you see and maybe not even get an interpreter. Getting information from the family, it makes it much more unique for the patient rather than saying, well, people from this ethnicity may think this way. Well, from the family may find information that may or may not be true. And lastly, at one point there was this issue that talked about cultural competency, but I think to become competent in every ethnic group, every racial group really is not possible, but it's really being more sensitive and being aware of all these differences. I believe this is my last slide. Thank you. Thank you, Dr. Dekishita, and I really liked the phrase in your last slide. Okay, Dr. Black, you're on and we keep going with our program. Thank you. All right, y'all, good evening. These slides look a little bit different than what I submitted, but we're gonna keep it moving and see how it goes so we can go to the next one. All right, so expectation setting. So often I give a talk one hour, two hours is the longest I've given. And at the end of every presentation, they wanna say, Dr. Black, fix it. Okay, expectation setting. White supremacy has been doing this for 400 years. We're not gonna fix it in an hour, but here are some bite-sized takeaways that I've learned to give over the years. Next slide. All right, so the first step is don't pressure yourself not to be racist. Think about it. Amongst the folks on this call, who likes Mercedes versus Lexus? I'm a Lexus girl. Do you know how many sharp, amazing, angry lines Lexus has? Yes. Is it rooted in fact? Not really. I just like Lexus. Coke, Pepsi, this team, that team, we are biased individuals and racism is embedded at the core of psychiatry, at the core of American society. So if you say that the benchmark is don't be racist, we're just going to justify all the racist things we do without using the language of frontal lobe recognition. So back to aversively racist providers. That's exactly what Dr. Takashita was talking about earlier. It's when we're exhibiting behaviors in decision-making that exemplify the bias that all of us have, yet explicitly we denounce it because it's uncomfortable. No one went into medicine and I'm sitting at $320,000 of student loan debt sup Biden? Okay, I didn't get this debt to be racist, but it's part of the tea. So black patients rated aversively racist providers the least satisfactory and aversively racist providers show towards black patients less positive affect, more negative affect, less engagement, and your outcomes were worse even if you were someone with racial bias who owned your racial bias. Think about it, just owning that we have bias is the first step to doing better. So don't pressure yourself to not be racist. That's absurd. Next slide. Next takeaway step is to celebrate detecting racism. When you find the racist elephant in the room, oh my gosh, we should celebrate it because disparities papers have been normalized. We talk about dead black folks in medicine, a dime, a dozen. Oh gosh, the next disparity paper of my ancestors, my people having disproportionate harms just came out. So it is everywhere and we ourselves must see ourselves a part of the next disparity. You can't fix it if you ain't a part of a problem. So celebrate when you find the trunk of the racist elephant. Oh my gosh, because you're light years ahead of everybody else. And then after you find the trunk, go find the tail, ah, go on a hunt because maybe a national leader in racial equity is one who openly embraces its flaws and hold accountability for iatrogenic racism. Some people ask Dr. Black, do you believe in training? No, not really, not really. Here's why. How many of us work with electronic medical records? Okay. I believe in accountability. Do you know how many studies I can run with a click of a button on an EMR? What if I said, ooh, Dr. Emergency Psychiatrist, your metrics show that you order restraints 20% more on black patients. I'm gonna hold you accountable or else we're gonna start talking about your paycheck. Dr. Pediatric Psychiatrist, what's up? I noticed that your black patients got diagnoses of conduct disorder three times more than everybody else. I'm gonna give you six months to work it out. What if we held accountability to black patients? Food for thought. Next slide. All right. So I want us to actively work to tear down the aversively racist walls between this siloed pocket of disparities literature and the siloed pocket of health equity research and real-time clinical practice. It's like three things going on at the same time. Next slide. All right. So one slice of the pie, we have real-time clinical practice. This is us with our good intentions, doing the best we can in a flawed system. I work in public psychiatry. I am working in a real flawed system. We still have paper charts in 2023. Yes, I said it. Our resources are very poor. We're doing the best we can. And stressed out providers make more stressed out decisions which activate stereotypes and tropes in our mind that perpetuate racism. But then we have this separate pocket of racial disparities. Remember, racial disparities by definition is retrospective. The folks are already harmed, which is different than the real-time clinical practice where you have the opportunity to stop the next data point from the racial disparities, which is still, again, siloed from health equity work. Again, what if we had accountability reach these other three spheres? And it's held together by aversive racism where we've come up with these defense mechanisms. Ah, well, the society told me not to be racist. And we have this black and white, all in, all out, you're racist or you're exempt. Oh, shades of gray, y'all. Can't pressure ourselves not to be racist. We don't have time for tonight, but go look up colorblind racism. Back in the days of Jim Crow, white hospital, colored hospital, Negro water fountain, white water fountain, back of the bus, front of the bus. It was overt and explicit with racist language. Today, we've just gone underground and this maintains the silos between these three pockets of work. Next slide. So think of it as the Berlin Wall. It artificially separated an entire nation for political, social, nonsense, discriminatory reasons. Families were torn apart. Well, families are torn apart by racialized inequity. Lives, families, livelihoods, everything torn apart. Next slide. But eventually we had to rally to tear down those walls and reunite a broken country. So what if we tore down the walls that are keeping us from talking about how these three pockets of information interact into one cohesive unit? Next slide. So view it as one cohesive unit, real-time practice, racialized inequity, health equity work. And how might you do that? I call it a racism time out. So in surgery, time out. This is Mr. Jones. He's here for a left leg amputation. Is this your left leg, Mr. Jones? Yes, are you here for this surgery? Yes, you verify what you're doing before you do it. We have all these safeguards for mechanisms of iatrogenesis that we are willing to talk about in real time. Remember, if you don't talk about it, you can't stop it. So many of us are at teaching hospitals with med students who are so eager to get published. So half of my publications have med student powered to it because, oh, these are some motivated individuals. And if I tell them kind of like a journal club, hey, go find me the literature on A, B, and C, bring it to our clinic the next day, and let's talk about ways we can implement this in our practice today. Oh, okay. Dr. Black, I found articles that Black folks are perceived as violent more often when there's no objective reason. What if we talk about violence in today's clinical practice? Awesome. And so we challenge ourselves to celebrate when we find the trunk, and doggummit, sometimes I found a foot too. So think about it. If you had a racism time out, were you brought in the literature, broke down that silo between disparities work and equity work, and challenged yourself to be accountable to the marginalized. Oh, so much fun. I think that might, oh, one more slide. Next slide, please. And the last thing we can do is change our language. Yo, we're psychiatrists, language is powerful. So instead of saying racial disparities, racial disparities points to my Blackness as the point of problem. Yo, I love my locks. I love my brown hair. Don't call me minority less than. It's not my essence, my identity that brings the inequity. It's racialized through all the policies that were painstakingly crafted to harm my phenotype. Okay, same thing. Racially minoritized points to the process. Minority says I'm less than. So as I fight for a nicer check here at Yale University, more protected research time, we noticed that Black women don't get promoted. Black women get this, Black folks get that. How can I advocate for equity if I'm literally calling myself less than? Minoritized, my friends. And lastly, many of our studies have white versus non-white language, as if the problem to be fixed is pigment. We are not studying white versus non-white when we're running these comparison studies. We're studying racially privileged and racially centered versus racially minoritized. If you're having a hard time figuring out if it's a social determinant or a racialization, think about it. If we repeated this study in Wakanda, in Zamunda, in a Black normative society, would I get the same outcome of dead Black folks? If the answer is no, then that is a process of racialization. You're not studying pigment differences. You're studying the differences of how society treats your pigment. So racially centered and racially minoritized holds the true culprit accountable better than white and non-white. And now I think I'm. Thank you, thank you. Come on. Okay, we lost audio from Dr. Black. I'm here. Oh, okay, okay. So you finished your presentation. All right, guys. Well, thank you for this great presentation as well. We're ready for some discussion here. I see some questions coming in already. One of them is, and I think this was triggered by Dr. Turin's presentation, but of course anyone can answer. Do you anticipate any revisions to the DSM regarding behavior dysregulation conditions, example, ODD? I'm probably not the best person to ask that question. Maybe someone within the APA that's on these committees, but I think that's why we revisit the DSM every so often to figure out what's best based on research and other things we're seeing in the field. And I know there's always a point in time too where you can also provide comments when they're reviewing. And so I think that that behooves many of us who are doing clinical practice and maybe see things a bit differently from a symptom point of view. But I guess that's my answer, although I'm not necessarily involved with that. Well, anybody wants to take a shot in that? Anyone else? Dr. Black, I see you wanting to make a comment. So my overall theme to all things DSM and misdiagnosis, rediagnosis assessment criteria is that Dr. Durham did a great job sharing how the foundational studies were normed on whiteness. Therefore the assessment criteria and all products of that work only work for the limited demographic it was studied in. So it's not that diversity is different, is that diversity is normative. So we need to go back and have, it's not that black kids necessarily experience or express depression differently, is that the way we define depression in kiddos never held our experience in the first place. And so I really challenged this slight frame shift in thinking as not going back and redoing the criteria, it's renorming it on a population that looks like the United States. Dr. Takeshita, would you like to make a comment on that question, the DSM and the diagnosis of ODD? Well, as a geriatric psychiatrist, I'm probably the least knowledgeable on this topic. So I don't wanna talk about a topic for which I am least knowledgeable. Okay, okay, fine, that's a good one. But I think the comment is very interesting about not that the disorders should disappear as such, but that the criteria that builds the diagnosis might be more inclusive or considering a wider study sample, which includes children of different groups. That's a very interesting thought. Okay, there comes another question. Dr. Black, could you expand a bit on the idea of the racism timeout? Interesting, they like that idea. Could you expand a little bit? Love it. So we often, particularly in academic settings, but all of us went through training at some point. Some of us went on to community practice, some of us stayed in the ivory tower, but it's this idea that we can intentionally seek out literature and then apply it to the clinic that day. And it's just practicing being able to detect the racist elephant in the room. It's practicing normalizing conversations of bias. And if you catch yourself perpetuating an inequity, right now, this detection is linked with shame, social stigma, ah, I failed. Where'd that JAMA paper come from of disparities? I don't know, but I am a failure because I noticed I did something that everybody else is doing. So the racism timeout is just a way to incorporate, tangibly set the stage, operationalize a way to talk about the bias that all of us are doing, but it's like the little monsters that only come out of the bed when you turn the light on. That is a completely unprovable hypothesis, right? If they only come out when you can't see them, then how do you ever know they're there? But we know racism is there. So find whatever creative way as a team leader, as a unit leader, as a department leader to incorporate, celebrate, not just lectures like this that are low stress, low risk, non-clinical. All of us can access our health equity knowledge because we're not stressed out. There's not 15 patients waiting to be seen. It's a very artificial environment. Practice health equity with a racism timeout, implementing strategies and normalizing the language without that extra palpitation. And that's gonna help you bring that into the real-time clinical practice. Excellent, Dr. Black. Okay, next question. Anybody who'd like to step up for this one. Where can I find a good list of disparities QI projects that I can implement in my hospital? Any ideas or suggestions that you could give? No? Okay, I think it's a hard question because, I mean, you submit references or something. Maybe we can figure out. I actually wanna be the chatty Cathy. Okay. So in medicine, this is medicine. Our brains are operationalized to have data before we act. But when it comes to undoing 400 years of bias and racism, often the scary part is innovating without someone else having figured it out before us. Right? So instead of wanting like a list of like, we fixed it, here it is, it doesn't exist. But I challenge you to go pioneer your own, get it wrong, get it right, get it all over the place. But any movement is movement away from the status quo. And don't pressure yourself for someone else to figure it out for you. You are that someone else. Well, you kind of answered one of the following questions which was, the racism timeout sounds like a wonderful innovation. Are there any publications or guides on how to implement this at our institutions? Thank you, Dr. Black. So I guess you address that with what you were just saying. Or give us a comment on that. Yeah, there's a lot to say. In three years, I've made 52 publications just because I'm getting all of these types of questions and trying to like put them on a keyboard. But no, I haven't had any luck looking for an operationalized racism timeout, but just use the model of journal clubs and things like that that we already have. Like we already have accountability mechanisms for most types of iatrogenesis. If you think of falls on the unit, right? First thing is we recognize when there's a fall in the unit, right? And then- And it's not good, but it happens. It's not good, but it happened, and I've recognized it. So from there, we can think of socks, bracelets, bell alarms. We already have a language of iatrogenesis in medicine. We don't have to recreate the wheel. We just have to be willing to recognize when it happens without shame and stigma. And then we can start thinking like physicians and quality improvers again. Excellent, excellent. Okay, I like the idea of bringing it into the vocabulary of medicine in general, which you identify another iatrogenesis, very good. Now, with that in mind, this is a very challenging question, I think, and maybe Dr. Takeshita can help on this one. How can we best serve marginalized adolescents in the virtual behavioral health, excuse me, on a virtual, yes, behavioral health urgent care setting? So emergencies, but in a virtual environment. Any suggestions for engagement? Wow, that's a tough one. That's a very tough question because I think adolescents in general are much more facile with virtual visits. And I think there's a lot of preference to virtual visits. Having said that, dealing with the emergencies on a virtual call is a very different game than routine therapy or med management because you need to have someone being able to look at the safety issues there. So in the absence of somewhat of a controlled environment, I think a behavioral emergency in a virtual call with an adolescent or adult or elder is, I think, is gonna be a challenge. Okay, okay. That's a very straight answer of how delicate this is, right? Okay, another question for you, Dr. Takeshita. Well, does the panel have any advice about how to encourage sincere reflection by emergency room colleagues regarding the use of the term excited delirium? It's used remains frequent, despite attempts to point out all the ways it is problematic. And any comments on that? I totally agree with you with the comment is that it's still used. People try to use it as a justification. Even amongst our medical colleagues, I think all we can do is to correct them and say the reasons why excited delirium really isn't valid. The term delirium is a valid diagnosis. Hyperactive delirium is a valid diagnosis, but excited delirium is not. So it goes back to education of our colleagues. That's one of our tasks as physicians. Got it. Okay, another question. What is the best way to enhance our cultural humility? Thank you. I love that question already. Dr. Durham. I'll give one example, but I think that there are probably many out there. So I'm sure everyone else has something to say, but I do think that even at a very personal level, if you think about your family and friends and you don't have anyone that looks outside of your cultural group, I think that's a good place to sort of start to recognize, I think, that media... We're even talking about sometimes our colleagues will say things about certain groups of people that are pretty derogatory and racist and discriminatory. And so how do we look sort of outside of ourselves and our friend groups, if you will, and think about who are the other people we're associating with to learn more indirectly by just having friendships with other people outside of your groups or your own culture or your own sort of preference for a certain type of person, if you will. I think that's one place to start. But I also think that constantly reevaluating what we're doing and how bias could have played a role. I know that in many of our clinical settings, and this is sort of the problem, it's a catch-22 because I think in some of our clinical settings, there's all of the clinicians are around the room or maybe are predominantly white and there's not enough diversity. I think I've been a bit lucky that people can question in sort of my groups that I've worked at, at institutions I've worked at, where there are people from different cultures to think about keeping our biases in check. And am I doing tunnel vision at this point and thinking about a case in a certain way and be able to discuss that with colleagues during like sort of a group supervision. And I think that's been really helpful for many of the colleagues that I've worked with. So I'm offering, I guess, two sort of examples of many more, but one just to start, I think how we break this, as Dr. Black mentioned, it's 400 years, but how do we break this? Who are our kids hanging out with? What are we saying to our kids and other members and our family about other people? And all of that starts at home, in my opinion, to really bring down some of these beliefs that we may have that we don't bring those beliefs into then the patient encounter. Okay. Anybody else wants to comment on this? You gave two examples already and very practical. Dr. Black or Dr. Takeshita. Yeah, I think the issue about culture humility, I think it's so important. I think the concept of humility in medicine is very much not done. It's a lot of kind of arrogance. And I think it has to do with the same thing is knowing what you know and knowing what you don't know and really asking, asking people for help. Hey, I'm not an expert in this topic. What do you think about this? That, you know, and that's where I think sometimes the patient's family can be helpful. They can tell you what it's like, not only with their culture, but it's what it's like with their culture and their family. And I've learned a lot from the patients that I've seen about specific things about their culture, but more specifically how it relates to that individual and family. Excellent. Dr. Black, any comments in this question about culture? Only briefly because my rockstar co-panelist dropped the mic and did awesome. The only thing I'll add is that in medicine, we have this model where if you read the book, you go to the training, you do a little extra work and you have mastery. If a surgeon wants to learn a new technique, they go to the robotic surgery training, come back, I'm certified to do robotic surgery. If a psychiatrist wants to learn a little bit more about psychotherapy, they go take a little extra training, refresh themselves on a book, I have mastery. But the way that bias is embedded so deeply into the air we breathe, that same sense of I took the extra CME credit, therefore I can check the box, it all falls apart. The more you learn, the less mastery you should tell yourself you know. Just think of aversive racist, again, they don't even know they don't know. So when they think they know, they're just messing it up all over the place. And so undoing bias is the one place in all of medicine where the more you do, the less you know, and we've got to learn a new model of being okay with that. Okay, well, we're getting to the end of our time here. And by the way, I've had so much fun listening to all of you and with the great questions that have been coming in. There's one more that I hope we can answer before our time is up. And I think it brings together how the bias can, as you said, you know, go take some CMEs on your new psychotherapy or neurobiotic surgery. This question is about standardized scales, right? So in this particular case, our colleague is asking regarding, you know, how they recommend this using scales to make more objective assessments. In this case, for example, agitation or aggression, and that it works as a tool for the decision-making relating the use of PRN medication or restraints like in an acute emergency setting. So the question is, are there any of those scales that may be more or less biased? What is your experience on that? And I think it's a great question. I had not looked at it that way, but you want to take on the first shot, Dr. Takeshita? Yeah, I think that's a really good question. My view about standardization in medicine and psychiatry is standardization is good. So much of what we do is sort of in my impression or on a gut level. And if you look at, for instance, diagnosis, if you use standardized measurements, there aren't any real differences in bipolar disorder amongst different groups. But if you look at what the patient is diagnosed with, well, there's all these differences. So I think if you look at objective measures, then it's better. But the difficulty with a lot of these aggression is it also includes how you feel about this encounter, that the amount of aggression from a 80-year-old who weighs 70 pounds is very different than someone who is 6'4 and 300 pounds, regardless of skin color. But still, is it better? Yes. I think it's still better. Could it be even better than what it is? Yes. But again, to get to that point is going to be a challenge. Okay. And before I let you go, I would like to hear about 10 seconds of... Because we're going to start to say goodbye now. Okay. Because we're almost at the end of the hour. We'll begin with you, Dr. Takeshita. You're asking about the last questions and last comments. No, no, no, no. It's time for us to wrap it up now. And as your last intervention for the webinar, what would you like to say? I think for the last intervention, again, continue learning, continue being humble. Okay. That was short and sweet and straight to the point. Thank you, Dr. Takeshita. Dr. Durham, we have a few seconds to say goodbye. We're about to finish the webinar. What would be your last comments? It's something that I think we've all said in our own way, which is just that there has to be continuous learning and discovering and thinking a lot about yourself and some of the decisions you make and being curious. Someone said about being curious of others. And I would also say being curious about yourself and why you made the decisions you made. It has to start with you as an individual. And so constant learning and thinking and evaluating, which is what many of us do, right? In therapy and other sessions with our patients, but also doing that reflective work with yourself to be a better clinician. Thank you, Dr. Durham. Dr. Black. Celebrate when you find the racist elephants in the room and don't wait for someone else to find it for you. Excellent. Okay. Well, thank you, Dr. Takeshita, Dr. Durham, and Dr. Black. And this was Looking Beyond, webinar from the APA. Please join us on March 1st for our next APA Looking Beyond session entitled LGBTQ plus mental health, challenges, advocacy, and clinical considerations for transgender and gender non-conforming persons. Thank you to my colleagues and great presenters. I had a great time and let's continue improving ourselves. See you in the next one.

American Psychiatric Association

Looking Beyond webinar series

mental health inequities

interdisciplinary lens

black psychiatrists

clinical bias

disparities in mental health treatment

cultural issues in emergency psychiatry

cultural humility