Good evening and afternoon for those on the West Coast. Welcome to the American Psychiatric Association's Mental Health Equity Fireside Chat, the Looking Beyond series. 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 American Psychiatric Association. And I will serve as your moderator this evening. So the title of our session this evening is Disentangling Race and Place and Their Implications on Mental Health Disparities. So what do we mean by race? So there's been an evolution, essentially, of the definition of race. There's the anthropological sort of classification that divides mankind into several divisions and subdivisions based on physical characteristics. There's grouping of people based on their ancestral background and societal identification. But by and large, race is not a biological factor. It's a social construct and essentially shaped by cultural and political considerations. So what is place? How are we defining that? Place can be a location, like the neighborhood that you live in, the place where you, you know, learn, work, play, worship, and age, the social determinants. It could be your position in society, in family, at work. So that's the race and that's the place. This evening, our panel will help us disentangle the implication of those two factors on mental health. So to set the stage for the discussion, let me start with a case example. So let's use clinical depression. Clinical depression, based on data from NHANES, which is the National Health and Nutrition Examination Survey, and we're looking at 2013 to 2016, the prevalence of depression in adults over 20. For African American or Blacks, it's 9.2%, Hispanics, 8.2%, and Whites, 7.9%. So we see that the prevalence is different across the racial categories. So is this difference that we see due to race or is it confounded by contextual factors like neighborhoods or place? And we know that neighborhood factors, for example, such as residential segregation, influence health outcomes and behaviors. Neighborhoods can influence our risk exposure, they can influence access to care, et cetera. So right now, for example, I'm in Washington, D.C., and in D.C., it is divided into eight sort of municipal units, also known as wards. And if you look at the neighborhood or residential areas in D.C. by their wards, and look at health indicators, you can see sort of this race and place and impact on health. So for example, Ward 3, Ward 3 is, on average, folks in that area have an income of about $222,000, $222,000, yes. And most of the residents are White. In Ward 8, the average household income is about $68,000, and most of the residents are Black. Now just let's look at two health indicators, life expectancy and infant mortality, and compare the two wards. So there is a 16-year gap, a 16-year gap in terms of life expectancy for those who live in Ward 8 versus Ward 3. And if you look at infant mortality, the rate in Ward 8, which has primarily Black communities with lower income, the infant mortality rate is six times higher than in Ward 3. So let that marinate for a little bit. We're going to talk even deeper about this race, place, implications on health with our distinguished guest. So let me introduce them to you. I'm going to introduce them to you in the order in which they will speak. I'll first start with Dr. Tom Leviste. Dr. Tom Leviste is currently Dean and Weatherhead Presidential Chair in Health Equity at Tulane University, the School of Public Health and Tropical Medicine. Prior to Tulane, Dr. Leviste spent 25 years on the faculty of the Johns Hopkins Bloomberg School of Public Health and served as the William C. and Nancy F. Richardson Professor in Health Policy and the Director of the Hopkins Center for Health Disparities Solutions. He has written more than 150 articles and leading scientific journals and authored and edited five books or more on minority health issues and cultural competency in healthcare. His areas of expertise include U.S. health and social policy, the role of race in health research, social factors contributing to mortality, longevity, and life expectancy, and utilization of health services. His work has been supported by major funders, including the National Institutes of Health, the Center for Disease Control and Prevention, the Department of Defense, the Commonwealth Fund, and the Agency for Healthcare Research and Quality, just to name a few. So welcome, Dr. Leviste. And Dr. Leviste will then be followed by Dr. Lisa Fortuna. Dr. Fortuna is a child and adolescent psychiatrist. She is the Chief of Psychiatry and Vice Chair at Zuckerberg San Francisco General Hospital, University of California, San Francisco. She has been an investigator on several NIH and foundation-funded studies of Latino and immigrant mental health, integrated care, and access to care. Her areas of expertise are child and adolescent psychiatry, treatment and research on post-traumatic stress disorder across the lifespan, immigrant mental health, access to care, and implementation research, including digital interventions to improve systems of care for disenfranchised communities. She is the PI on a PCORI, or Patient-Centered Outcome Research Institute, grant. This is a multi-site pragmatic trial on the treatment of childhood anxiety called Kids Face Fears. Welcome Dr. Fortuna. And Dr. Fortuna will be followed by Dr. Michelle Reed. Dr. Reed is the Chief Medical Officer for CNL's Healthcare, a nonprofit certified community behavioral health clinic in Michigan that serves over 7,500 children, adolescents, adults, and senior citizens with mental disorders and substance use disorders. She is also Clinical Assistant Professor at Wayne State University, Department of Psychiatry and Behavioral Neuroscience. She has served in various leadership roles in her professional career. Currently, she is Trustee-at-Large for the Board of the American Psychiatric Association, Chairperson of the American College of Psychiatrists, Dean Award Committee, and Area 4 Representative to the APA Assembly for the Michigan Psychiatric Association. Dr. Reed is a visionary leader with a track record of serving the community. She credits her commitment to psychiatry and the profession of mental health to her parents, both of whom served on boards of community health centers in her hometown of Detroit, Michigan. So welcome, Dr. Reed. Now, before we get started, I just want to take a second to thank our APA President, Dr. Vivian Pinder, our CEO and Medical Director, Dr. Saul Levin, the members of the APA Board of Trustees, the Councils, Assemblies, Caucuses, and Administration, all of those for their continuous work and support in advancing mental health equity. And with that, I will pass the virtual mic to Dr. Tom LaVeist. Okay. I think you're on mute. Yeah, I'm having some problems with my internet. Let me just... I can't talk to you. I'm sorry. I'm having some problems with my system. Just give me one second. Sure. Not a problem. Not a problem. Okay. Give me one second. Can you verify that you're seeing my screen. I'm seeing your desktop. I'm sorry I'm just, I'm not sure why I'm having these, I see part of it now that I see the PowerPoint at the bottom. Yes. Now, I see it. You see it, but I see the whole screen I see your initial screen as well as your next slide. Now you're seeing the wrong screen screen. Okay, I'm sorry again. Would you like for us to do the slides on this end or. There we go. All right, so we're set up correctly now, we are now set up correctly and again I hand the virtual mic off to these technical problems you think after two years of living on zoom that the systems would just come right together. So I'm going to try to do this really quickly because I'm really looking forward to engaging with my panelists and my colleagues on the panel and hearing their remarks, but I want to just kind of make a few points about this issue of disentangling race and place and the complexity around that and why I think it's really important to have this conversation and I'm really interested to hear it from the mental health perspective as someone who is not a mental health professional. The examples I'll give will not be mental health examples but I think you'll see the relevance of what I'm, what I'm trying to present to you. So this chart shows the basic issue. This is the summary chart of racial inequities, showing race different of all, and African Americans have the African American males have the highest mortality rate. So, like this pattern is pretty well known I think it is to this audience. But when we talk about the reasons for this disparity, these disparities these inequities I should say. Basically, most people, when you talk about it comes down to these three popular myths about why these disparities exist, and these are myths these are not the reason, and I put that here because I want to try to just make that point really clear. It's not about the healthcare access issue there, there is not about biological differences between race groups, and it's not a simple matter of poverty or socioeconomic status, and the issue of poverty and socioeconomic status in this in this confounding with race is something that is probably the most common that I encounter now and we'll talk about this. So I put together just a series of charts here showing race differences in rates of different conditions at using education level and I have a few charts showing And it doesn't really matter very much what condition you look at the pattern is the same across all levels of economic strata here measured by income, my education, and I'll show you a few by income as well. You still see a disparity. So, often, more affluent or highly educated African Americans believe that this is really an issue of poverty or low income black people or other people of color, but this is not the case there is a social class or racial status effect, but there is a true race difference as well. We really do have a problem with inequities and race, and here I'm showing some more charts from the national panel maps data set which again shows the same disparities. So if it's not genetics or healthcare socioeconomic status, then what is it, what is the driver and I would argue that that driver really comes down to place. The fact in my place what I'm talking about is the fact that we live in this country together, but we experienced the country very differently, because we live in dramatically racially segregated places. This is a chart. This map was created by the University of Virginia. This is based on the 2010 census, not 2020 so it's a little bit old, but the, but the results here are no different than if we had the 2020 census available. So what they did was they placed a dot on the map, representing every American so they're over 300 million dots on this map, and they are color coded by race so the blue dots represent white Americans green African Americans, red is Asian and orange represents Hispanic. As you can see, there are clear, clear patterns here where, where people have different racial and ethnic backgrounds live in different communities across the nation. Here I focus in on Washington DC which I think is a good city to show clear pattern where the green dots are mostly to the east of the city. And if you're familiar with Washington DC, then you would know that this is mostly the green dots are mostly in Prince George's County, the blue dots are mostly to the west of the city, and that is northern Virginia, or Montgomery County, the orange dots and the red dots are intermixed in. And this is the pattern that we see across virtually every city in this country. DC is not in any way unique Robert Johnson Foundation illustrated the same thing a little bit differently. They created a map based on for the subway lines or metro lines in DC, showing that if you get on the metro to go home after work, depending upon which line you get on, we can predict your life expectancy and if you're getting on the green line going into Prince George's County, which is mostly African American life expectancy is 75. If you get on the orange and blue line going to Northern Virginia, which is mostly white your life expectancy is at in Montgomery County, which is also mostly white on the red line life expectancy is at one. To pick on not to pick on Washington DC here's New Orleans and we see a similar pattern with the green dots to the east of the city, New Orleans East blue dots mostly to the west of the city going into memory and Jefferson Parish. And finally, here's my hometown of New York, New York is truly a rainbow. We see all colors here. However, we see clear lines of demarcation where one color ends and the other one picks up because New York is dramatically racially segregated as well. So, just to orient you a bit here on the map, if you can see my cursor this is Manhattan Island that I'm sure that I'm circling with the cursor, and in the middle of Manhattan Island you see this office white all white rectangle here. That is Central Park, and the idea is that no one lives in Central Park. And of course that is untrue as a former social worker that used to call on clients in Central Park. And it used to be my job to actually check on people living there. So I do know that there are people living in Central Park, but I think the pattern is clear that the city is dramatically racially segregated. So here I've circled Brooklyn. And if you know anyone from Brooklyn and you know that people from Brooklyn believe their Brooklyn is the center of the universe, which is why I circled it. And of course Brooklyn is in fact the center of the universe because I'm from Brooklyn, but that massive green in the middle of that of Brooklyn is the neighborhood where I grew up in a community called Brownsville. Brownsville is 86,000 people living in a little more than one square mile. It's double the population density of the rest of Brooklyn, and the way that you get that many people into that small of an area is you build up in this in this way. There are clear health implications in living in environments like this, and I would venture a guess that there are mental health implications as well. So, this is the building where I grew up as a kid and this is the elementary school that I was supposed to have gone to, except that the school was condemned. A few weeks before I was supposed to start there as a kindergartner and that building has been vacant for the last 50 years now. I went there last winter to take a picture of it, because I wanted to show that the trees have actually grown through the building and out the roof. You can't really see it very well because it didn't occur to me that in the winter there would be no foliage on the trees, but if you look closely you can see some of the branches from the trees, because this building has been abandoned for so long. And as we look at some other photos of the neighborhood, you see a bit about the food environment, the kind of foods that are available there. So, which tells you something about the diet that people eat, and therefore the way that people's health is impacted by these social factors in the communities where they live. This is a picture of some kids I took, because if it was about 50 years ago, I probably would have been one of those kids. But if you look right above their head, we see crown fried chicken, which is ubiquitous in northeastern cities. And here in the upper left corner we see a sign from a Chinese takeout restaurant, which dominates the food environment. Here's some pictures of Baltimore City, my adopted home, and we see corner stores, which are again ubiquitous throughout Baltimore. These stores sell pretty much cigarettes, malt liquor, cheap wine, lottery tickets, and the occasional, some food stops. This one, this picture is from a store that was just a couple of blocks away from my office at Johns Hopkins when I was there. And then of course this is my favorite one. This picture shows a sign, which I appreciate because of the truth in advertising. L&M Liquors, they sell beer, wine, and medicine, and I did not Photoshop this picture at all. This is on North Avenue right off Greenmont, if you know Baltimore. And of course the medicine that they sell is the medicine for the ills of poverty. It's the medicine to treat poverty. They sell malt liquor, which is not beer, which has about double the alcohol content of beer, and is sold in much larger denominations of 40-ounce bottles, 64-ounce bottles, and 32-ounce cans. I've added a 12-ounce bottle of Miller beer here just to give you a sense of proportionality. We did a study to look at the location of the stores that sell these products in Baltimore, and we found that if you look at the census tracts where these stores are located, they're almost exclusively located in segregated, predominantly Black communities. And here we define predominantly Black by at least 95% Black living in the census tract. Even with such a stringent definition, we still find that that's where these stores are located. So this segregation is critically important because it creates an infrastructure that allows for differential access to resources that are helpful in producing a good quality of life and good health, but it also creates an infrastructure of access and exposure to health risks, which is why, even though we live in the country together, we experience the country very differently. And when we use national statistics and look at race differences, and we try to draw conclusions about race differences on those national statistics, that we have not accounted for the fact that people are living in very different health risk environments. So we see the disparities using the national data, we don't account for the fact that they're segregated and living in different risk environments, and then we assume that the differences we see are endemic to the people, rather than endemic to the environments where they're living. So, we got an idea that what if we could do a study of people, Black and people of different racial and ethnic backgrounds who are living in the same neighborhood. If we had the same economic status. Would we still find the same race disparities. So, we, we got data from the from the census to identify census tracts there 168,000 census tracts in the United States. And we found 425 of them that were racially integrated. And also did not have race differences in income or educational status. And this is the criteria that we use at least 35% Black and 35% white living in the same census tract, and where the income and education levels are very similar. And then finally for us to those census tracts were in Baltimore and they were contiguous. So we went into those two census tracts, and we replicated portions of the protocol from NHANES and health interview survey, two of the most well recognized and best known data sets that's created collected by by the federal government. And we replicated that those studies in that in that community, so that we can determine whether or not we see the same disparities when people are living together. In other words, we're able to disentangle race in place, or when people are not living in segregated environments. So I'll just quickly go through just a couple of slides here on this community, the community is two census tracts in southwest Baltimore 51% living there is Black 44% living there is white. There's a median income is low and as you can see there's no significant difference in income levels, both populations are equally poor poverty levels are high and as we can see again, no significant differences in poverty levels. No significant difference in educational attainment across the populations and no significant difference in distribution of sex, and in these in these two census tracts. So this is about as close to a laboratory setting as you can ever find with a naturally occurring community. So when to these two census tracts we conducted the 40 minute interviews and exams and following NHANES and Health Information Surveys protocol, and we succeeded at interviewing 42% of the adults living in these two census tracts. So, I won't spend too much time on these next few slides. These are just showing how well we represented the sample, the red bar represents our study, the blue bar represents the census and what they found. And you can see our statistics and our distribution of these variables seem to be very similar to what the Census Bureau found, which you might expect given that we have 42% of the adults in our study. So the way we do the analysis is that we conducted, we go into the research literature, we identified a paper, and I'm going to go to this next slide. We went into the research literature and we identified in this case, four papers, each represented by model one through four, identified four papers that use NHANES to look at the question of race differences and blood pressure or hypertension risk. And along the column labeled NHANES 99 through 04, you see the results that we got when we replicated their analysis. Odds ratios range from 2.01 to 2.25. So this is about what we would expect and what we teach currently in our classes in medical schools. We teach students that African Americans blood pressure, or about twice the odds of whites being hypertensive. And we normally teach, we make that statement and we teach that without providing any context. And since we don't provide context, many of the medical students then conclude that there must be something biological about that. The next column labeled EDIC is where we replicated the exact same analysis in our data set. And remember, we follow the exact protocol of NHANES and health interview survey. So we measured everything exactly the way that they did, and we did the analysis exactly the same as the analysis that was on the paper. Consistently, when we do that, we see a smaller odds ratio here ranging anywhere from 29% smaller to 34% smaller, which suggests that the disparity that we see in NHANES is not about something endemic to the people. It's not about some biological thing that's producing this, but rather it's social. It's happening in the social determinants. So with hypertension, however, we weren't able to explain all of the race difference. On other conditions, we did a similar analysis for diabetes, obesity among women, and use of health services. And we've now done this for a much larger number of papers of conditions. And the pattern is consistently the same. So for diabetes, we had in the national study, the national data, about 61% greater odds for African-Americans to be diabetic compared to whites. But when we're able to account for place and look at people living in the same environment, we see no significant race difference in obesity. I'm sorry, in diabetes. For obesity in the national study, 87%, that black women, 87% more likely to be obese compared to white women. But in our sample, again, no significant race difference in obesity among women. Hypertension, we've already talked about. And then finally, health services. This is use of preventive health services. In both cases, we do find a non-significant effect, but it is instructive, I think, that we find a different direction of the relationship in the national study versus in our study. And our study has a confidence interval of one to 1.87. So it is very nearly a significant effect. So this chart just summarizes those results. And so what we conclude from this is that we're living in the country together, but we're experiencing the country differently because we're exposed to different health risks. When we're exposed to the same health risks, we find that the disparities that we see between race groups either go away entirely or they become dramatically smaller, suggesting that the etiology of these disparities is not something endemic to the person. It is very unlikely that it has anything to do with their biology or genetics, and it has much more to do with place, where you are living and what exposures come as a result of that. So I will stop my screen share and turn it back over to Dr. James. Well, thank you so much. That was a fantastic presentation. And now we will turn to our first discussant, Dr. Lisa Fortuna. So Dr. Fortuna, would you like to begin your reflection on Dr. Levy's presentation? So, I mean, I agree this was an excellent presentation, and I think it really brings home what we see also in mental health disorders in terms of how place can have a direct impact on outcomes. And I wanna focus in a little bit, if I can, on child and adolescent populations and families. So if we look at things even in terms of development and mental health outcomes for children and youth, more and more research is showing exactly what Dr. Levy has shown in terms of other health conditions, that place definitely matters, and it's not only sort of access to mental health services, but that there are definitely social factors that impact on young people's development and mental health outcomes, and that there's policies that impact directly on their mental health outcomes, and that really as psychiatrists, child and adolescent psychiatrists as well, we need to be able to address at all those levels. So I'll give some examples from the research and how I think about that from a clinical perspective and how we're looking at this in terms of child and adolescent mental health. So one particular study that I've become a bit involved in is one that's coming out of Columbia University and other institutions. That's called the Boricua Youth Study that some people listening might have heard about. And really this was a study looking at Puerto Rican youth as a large Latino, Latinx population in the United States and looking at mental health outcomes for youth who are living in the Bronx, New York, versus living on the islands of Puerto Rico. And what we know is that they use, I mean, this study uses a very important child development model, which I think is really important. If people can look at it, which is by Garcia Cole, that was developed in 1996 actually. And really what that model says is that the development of youth of color is really defined by that when youth of color, especially are marginalized, is a multi-dimensional dynamic, context dependent and diverse web of processes rooted in power and balance. So power and balance and systematically directed towards specific groups that are racialized with probabilistic implications for development of mental health problems. So one very sort of distinct example that I can give is a paper that I'm currently writing that is looking at the probability of having PTSD symptoms and the severity of those PTSD symptoms given exposure to trauma and looking at youth who are residing in the South Bronx over time versus in Puerto Rico on the islands. And one of the things that we found there's some of the interesting pieces was that the youth in the South Bronx were more likely to have higher levels of PTSD symptoms given exposure to traumatic experiences including abuse and sexual abuse, more likely to have higher symptomatology in the South Bronx than in Puerto Rico. And some of the factors that played into that were neighborhood context in terms of support, resources in the community, culturally salient resources like religiosity, community organizations, and being in a context where you just have additional social supports and resources. But the interesting thing between the two places was that we also looked at the experiences of discrimination and what we found is that in both the islands and in the South Bronx, discrimination is still related to having elevated PTSD symptoms given exposure to trauma both on the island and in the South Bronx, right? And so some of the things that we found interesting in there is that we thought minoritized status in the South Bronx, there would be higher sort of relationship around that discrimination and mental health outcomes. But in reality, what we found is that in other papers as well, of the other authors of the other investigators of the Puerto Rico study, including Christiane Duarte is finding that there is also discrimination around colonial context in Puerto Rico that still affects young people as they're growing up on the island and that that is related to elevated PTSD symptoms given exposures to trauma. So that just sort of is one sort of example of how dynamic and complex this idea of context and environments can have on mental health outcomes. And I think we're looking at that more and more, right? When we're thinking about how do we address issues around increasing suicide in black youth, right? Who are even pre-adolescent in age in the tremendous increase of suicidality and suicides in that population. And again, we're having to look at it in a multidimensional way, right? It's not just that the young people are black youth, but it is really around the sort of circumstances of power and balance, like I was talking about and systematically structural inequities that young people experience, not only in access to mental health services, which is one piece of it, they're not accessing mental health services when under distress, but that also that there are multiple environmental issues that are racialized, including discrimination that can have a direct impact on things like post-traumatic stress disorder, depression and anxiety, and elevation of other mental health problems, which are not related to their racial, who they are in terms of racialized identity, but much more so on the discrimination and social contextual disparities and inequities that they experience. So that's just one example. And so what does this really mean in terms of to sort of get us started, what does this mean clinically? I think it really means that for us as psychiatry, we have to think outside of the one-to-one clinical sort of space alone, right? I do think in our clinical settings, we do need to be able to address, understand, identify those issues that are contextual, that are impacting on the young people and the families that we are caring for and serving. But we also have to look a little bit more upstream in terms of how do we really look at how their social position, how their school system is supporting them or not supporting them. Dr. Lovese was talking about his school, that he's supposed to be was condemned, right? And so there's a lot of schools that with very limited resources are trying to support kids. So I think it's the role of psychiatry and child psychiatry to think within those more systems and structural inequity frameworks of how are we supporting kids in schools? How are we integrating more prevention? How are we making sure that young people have the resources that they can thrive? And when they do get to our clinical settings, are we addressing racialized trauma? Are we addressing discrimination experiences? And are we designing our interventions and services to actually be more accessible to the community and more equitable? So those would be some of my sort of immediate reflections and responses from a child and analyst developmental perspective. Okay, thank you so much, Dr. Fortuna. She brings in that developmental lens, that life course perspective as we have this conversation. So thank you so much. Next we'll have Dr. Michelle Reed. Dr. Michelle Reed, if you'd like to share your reflections on Dr. Louise's presentation. Thank you so much for this opportunity. You know, I've worked my entire career in the public mental health system for 40 plus years. And right now I'm the chief medical officer of a certified community behavioral health center. And I would tell you that place definitely matters and that community mental health, a place where persons with chronic mental illnesses receive services, it's absolutely a place. And I can just look at my own home state of Michigan. We were involved with the National Association of State Mental Health Program Directors Research Institute looking at the cause of death of people in the Medicaid and the public mental health system. And we found out some very interesting facts about people who died who were receiving public mental health services. That hypertension is in the top 10 causes of death of people receiving public mental health services in Michigan, but it's not in the top 10 causes of death either in the county where I work or in the state of Michigan or the United States. And when we dug even deeper into the data, we actually saw that it was 9% of men were dying in the public mental health system due to hypertension. So it was not something that was affecting women. So right there, there was a disparity that we were seeing being male and being part of the public mental health system top 10 causes of death, hypertension. The other thing we were just looking at is the age. I mean, you're served in the public mental health system. The average life expectancy is 57 years. However, if you were just having Medicaid and had mild to moderate illness, your life expectancy is more like 62 years, but overall residents in the state of Michigan life expectancy is 75 years old. So the public mental health system is a place for care with persons with a serious mental illness, substance use disorder and developmental and intellectual disabilities get care and absolutely place matters. One thing that I'm working with right now where I work is something we call a crush COVID. We actually did a heat map and looked at where were the people who we served who were not vaccinated? And we all know that persons who have serious mental disorders are more likely to have severe COVID disease. And we actually looked at the vaccination rates among the people we serve. And we saw that in our general County, 66% of all people are vaccinated, but overall only like about 44% of people receiving public mental health system were vaccinated, fully vaccinated. And it got even worse for children and adolescents and people with substance use disorders, both only 20% vaccinated. So we're working on a project now, a crush COVID to really look at what can we do to improve vaccination rates all over? And I think basically what is it that we can do to improve or to reduce disparities and improve access to care? And I say that certified community behavioral health centers is the way to go. We need to expand the certified community behavioral health centers nationwide with our focus to serve the underserved, underinsured and uninsured with a main focus on the LGBTQIA plus population, Native Americans and veterans. And this is just most important. What can we do? It just takes a few minutes to write a letter to your legislator. We've got three bills out there now that really would allow us to expand these certified community behavioral health centers nationwide. We've helped over 100,000 people over the last four years, hired child psychiatrists in over 430 clinics. And the Excellence in Mental Health Addiction and Treatment Act is out there, Senate Bill 2069 and House Bill 4323, two important bills. The APA is working to lobby for these bills. Please, please write your letter to federal legislators and let them know, co-sponsor these bills and to support expanded funding for certified community behavioral health center. And another more recent act, working with the American Psychiatric Association, the Mental Health Justice and Parity Act has been sponsored, House Bill 7254, and this is gonna provide expansive funding for the 988 crisis services, crisis intervention services. So these are some practical things we can do to take action to improve the place where people are getting mental health care. Thank you. Thank you. So thank you, Dr. Reed, and thank you for sharing all the information about the legislation, because we know policy is very important as it relates to addressing mental health and mental health inequities. So if I can bring all of the speakers back, Dr. Lopez, Dr. Fortuna, and we can begin to answer some of the questions that have come in so far. One of the first questions is, how do you address the medical curriculum when you're teaching students that a particular race is associated with a particular mental health diagnosis? If in fact, contextual issues are important. I guess, how do you reteach medical students if it's more about contextual issues versus just race? I think that one area, I've been really impressed with the work. Actually, I did journal club today with the residents and this very article discussion came up. We were talking about an article on the use of ketamine for severe alcohol use disorders. And it was a study in the United Kingdom and it didn't address race or place whatsoever. And the resident was talking about his difficulty working in an urban setting in a community hospital and how the perception of African-American male patient he had was there yelling and screaming at the staff who he was in the middle of a manic episode and how he felt that the person was treated differently than somebody else would have been. And I found the resources at the American Psychiatric Association to be simply wonderful for residency training. The Council on Families wrote a paper about how to talk to patients and families about race. There are many resources out there on the website, looking at structural racism, social determinants of mental health, and a wealth of experience in the Division of Diversity and Health Equity. I think that's a place where there's a lot of information for residents to look at, for clinical instructors to look at, just a whole wealth of information there to really say, how do we reframe this conversation? But it's down to, at Journal Club today, that was exact conversation we were having. I didn't want to add one other point to that. I think you're right. We have to address this issue. It's not sufficient to simply say, African-Americans have double the odds of being hypertensive compared to whites and then stopping there. That's the problem. That's what happens. They don't get into any discussion of the context, and that leaves people thinking that there's some biological reason why these differences exist. Most people who are teaching in medical schools don't know this information themselves, and so they're continuing to pass along this inaccurate information. The other thing we have is a problem with who we decide to let into medical school in the first place. I've asked countless physicians this question now, how much organic chemistry is involved in your daily work? I have not found one person yet to say that they rely on organic chemistry. We use organic chemistry to determine whether or not you get into medical school. Then I say, well, how much psychology, counseling, social work is involved in your job? Every single one of them say, I feel like I'm much more of a social worker than anything else. Why do we continue to use organic chemistry to weed out who gets the privilege of getting this education as opposed to using metrics that are more relevant to what you would be doing when you're actually doing the job? I don't think I even use organic chemistry in medical school. Not like the way they taught it. It was only to determine who couldn't go to medical school. Who can get in. Right. If you've got a good enough grade, you can get in. I would just really quickly, because I know we have other questions. I think it's a very clear, intentional, completely revamping of our curriculum. I mean, the idea of race is not the construct to focus on. It has to be integrated in all of the coursework. If you think about it in medical school from day one, it's explicit derailment of that misinformation I think throughout the curriculum. Yes, absolutely. Another question for the panel. Has there been analysis done on the threshold for the length of time spent living in environments that lead to poor health outcomes? For example, do the impacts of place-associated risk emerge within one generation? I mean, I think immigration is one place that we can look at. A lot of our studies, what we found was that when we were looking at the National Latino and Asian American Study, then Margarita Alegria led, which really looked at, was the largest study of Latinx, African-American, and Asian populations in the United States, nationally representative. What they found is that people who were born here in the United States have worse mental health than those who were born outside of the United States. But those who came here before age seven had similar poor outcomes as compared to people who came much later in their life. To me, that points also to a developmental components in your early development and the exposures that you have of inequities and discrimination and other things, the resource-poor environments, the nutrition, everything else. The earlier you're exposed to that, it's a problem. But I do want to talk about discrimination piece and the experience of being minoritized and racialized in the United States. Because you would think that some people who are coming from immigrant populations maybe had poverty or low resources to some degree, coming into the United States. But there's something around the interaction of being in this environment where you are minoritized and marginalized that has a very negative impact on at least mental health outcomes. I would agree with all of that. I would add one thing to that, is that you have to be very careful in making comparisons between immigrants versus people in the host population. As the son of immigrants, I can tell you immigrants are not normal. They're not normal people. Somebody who's industrious enough to pack up everything they own and move to another part of the planet, is not somebody that you can compare with somebody who didn't do that. That's a very unique population. I do have some issues with that part of that study. But as far as the exposure question, and I think the rest of it is accurate. Next question. If place more than race is impacting mental health outcomes and minority communities have less access to care and lower quality care, how do you address this place issue when you're trying to improve mental health outcomes? Well, I think for me, the certified community behavioral health provides evidence-based treatment over a number of quality parameters that are consistent throughout each community over the entire nation. Expansion of the certified community behavioral health clinics nationwide to me is that answer because it creates a firm quality improvement platform. Certain metrics and data are collected on a federal level and care that is provided is according to evidence-based practice. This is the quickest way, I think, and the most efficient way. What we need to do is to have the certified community behavioral health centers be like the federally qualified health centers, to even the playing field nationwide. That's my solution. Dr. Reed, maybe can you expand upon the benefits of working in an area such as you do? Because early psychiatrists who are coming out are, by and large, probably not looking at the benefits of working in a community health center or a federally qualified health center for that matter. Yet, that is where most of your marginalized and minoritized individuals may come to get their health care. Oh, absolutely. I can just tell you how many nationwide, thousands of staff have been able to be hired from the additional funding that we have. Very often, the state and county and local funding on Medicaid cover maybe 60 percent of what it actually costs to deliver care. With the certified community behavioral health clinic demonstration state, we're actually reimbursed for what it actually takes to deliver care. We've been able to hire child psychiatrists, a number of them around the country. We've been able to expand our psychiatric services, expand services of pharmacists. We're even getting ready to add two dieticians to our staff. In Michigan, for instance, just the whole idea about you have Medicaid, you can only see a dietician if you're already diagnosed as diabetic, but yet we're working with an individual who weighs 600 pounds and we're not able to secure dietary consultation for her. It's really affording you to put the resources you need in place to really help people. We've been able to take more medical students. We had not really had enough staff working with us to have med students. I have med students from two different schools with us, and we're working with three different psychiatric residency programs to offer them the ability to come. Also, in many of the areas where mental health professional shortage areas, one of our clinics, I think I just saw the letter this week, where another one of our clinics is going to be able to participate in student loan repayment, so it's very helpful. But you bring out a good point. Working in community mental health, the average age of the psychiatrist working in Michigan is 60 plus years old. I am one of the youngest psychiatrists who works where I work, and they're all receiving social security benefits. I have one who's retiring next month who's close to 80, and the pipeline just has not really been there behind us because, I mean, frankly, the student loan repayment issue. I came out of medical school in 1980 owing $10,000, and my school repayment was $107 a month. We have people now who really, this is a major issue. They're owing hundreds of thousands of dollars, and really, we're doing some things in Michigan around that. Our governor is doing some things with the state of the state, but these federal student loan repayments have been a wonderful thing for us. We just had our chief corporation counsel, and he's in his 50s. He still was owing like $60,000, $70,000 from law school, loans all repaid back. So several of our staff have been very successful in negotiating these various loan payments, getting into these direct loans, and really, they got to push this as a federal level. We have got to get this student debt under control so people could consider coming to work in a community mental health setting where they may not otherwise go because they're sometimes paying seven, eight, $900,000 a month in loan repayment. It's like a house note. So we have got to really advocate for broader expansion, the student loan repayment. Okay, thank you. Thank you very much. I appreciate that. Next question. I know, Dr. Fortuno, you mentioned the importance of not only place, but the policy issue as well. So the question is, when wanting to influence policy concerning racial and mental health disparities, should you focus on local, state, or federal policy level issues? I mean, I welcome the other speaker's thoughts too, but I think all levels, right? I mean, I think we need work and everything. And if you think of your local context, I think that's a good place to start, right? And we have to think broader from outside even healthcare is what I wanted to sort of bring up too. Like we need to think about how the local policies affect young people accessing healthcare services, right? But I think we also need to think about policies that are affecting them across their systems of care, right? So schools, right? There could be things like policies like zero tolerance of how kids get pushed out of schools, right? For behavioral issues, or what kind of sort of daycare services. So there's so many sort of local policies and public health things that one can get involved with. And then at the higher levels, any policies that relate to access and quality of care and education, I mean, all of those are relevant, but we can definitely start. I think the local is always the place to start. Oh, I would absolutely agree with you. One of our largest clinics is sitting in a suburban Detroit community where they never passed the millage for public transportation. So there's no bus service in the entire community where we have hundreds of people that we're serving. So, I mean, that's an example of a local issue of a place. People have trouble getting from point A to B if you don't own a car. And working with the community, identifying those things, I would state, right? Because there would be some things that you wouldn't even think about how they're- Yeah, our needs assessment, absolutely. I think it's critical as a health policy person, it's critical that more people, more health professionals get involved in policy and become sophisticated about where policy is made. It's met at all levels of government, but it's not only made in the legislatures. Much of the policies that impact our lives are made with, there are regulations that are written by regulators in the executive branch of the federal government or the state government. And the other thing is that corporate policy. There's no government policy that makes one community a food desert and another one not. It's corporations that are making decisions about where they're gonna locate. So you have to be active across all levels of government, but you also have to be active in corporate policy. And so there was a question. Physicians are not often trained in health policy or understand their power to influence policy. How can we change this? Yeah, right. I'd love to have you guys come and get your health policy training from us because we need that. There is nothing stronger, nothing more impactful that I have personally seen while testifying than somebody to come up and say, well, last week I was in the clinic and this is what happened. That is such a powerful way to be able to begin a story and it has a huge impact. We need more clinicians to understand how to be effective in the policy realm. And I would say for me, two things got my interest. Both of my parents were on community mental health boards. I was actually on a community mental health board during my psychiatric residency. And I think the APA fellowship exposed me to a lot of policy. So I encourage any of the residents out there to look at those APA fellowships as a means to learn about policy issues. Those were very influential for me. Yeah, and so I would think any of those training programs and then also just getting involved in your local sort of boards and communities and going to those and learning while you're there. They often want psychiatrists and physicians and others to participate in that and bringing their expertise. Okay, so we have about one minute left and I would hope that each of you maybe could give just a closing remark around just some nugget that you want folks to take with them about this issue, disentangling race, place and mental health disparities. So I will start here in the upper corner. Dr. Reed, I'll start with you, Dr. B. Please, please, please take two or three or five minutes to write a letter to your legislator and support the bills that are going to expand access to certified community behavioral health clinics and the 988 crisis services. Funding for services is key and a letter to your federal legislature can make a big difference. Take a few minutes and do that, please. Thank you. Dr. Fortuno? I would say, yes, definitely get involved with these policy and legislative things, both locally and moving on beyond that. But the other thing is I would say is, take some of the things that we've been talking about today and if nothing else, reflect on how that might impact on your clinical practice. Like some questions you might ask yourself in seeing a client and really our patient and thinking about what might be really impacting on their lives. What you can do locally to impact on what we've been really talking about to the social structural pieces. Every little piece that you can get involved in is highly impactful. And how can you transform your teaching and training if you're involved in that in the ways that we've been talking about today with your learners that you work with? Thank you. And Dr. LaVeist, you have the last word. And I agree with both of my colleagues on the panel. And my ad would be that biological race is a fiction and we need to stop thinking in terms of this group has this condition and that group has that condition. They have those conditions because of the social exposures, the environmental exposures and health and the behavior related exposures that make it more prevalent in one condition and one ethnic group versus another. It's not about the endemic, anything endemic to the people. It's the culture. Okay. Well, again, thank you so much, Drs. Reed, Fortuna and LaVeist for a fabulous discussion around disentangling race and place and their implications on mental health disparities. I hope everyone who joined the webinar had wonderful experiences I have. And if you haven't, you will also have this on the recording if you've missed anything. So please, please, you know, take a look at it. This has just been such rich information and I see our next symposium actually at the APA Foundation. I mean, at the APA Annual Meeting is also up. But again, thank you all. It was wonderful. And I hope you enjoyed it. Thank you.

Mental Health Equity Fireside Chat

Disentangling Race and Place

Mental Health Disparities

social determinants of health

access to care

racial segregation and health outcomes

improving mental health outcomes

integrating mental health services

healthcare professionals and health policy

comprehensive approach to mental health disparities