So, good afternoon, and thank you so much for coming. My name is Maria Okendo, and I'm not standing behind the podium because then you would not be able to see me. And I am very honored to have the opportunity. Director of the NIMH-funded Columbia University. Dr. Weinberg is also the chair of the Mental Health HIV Clinical Guidelines Committee of the New York State Department of Health slash AIDS Institute and principal investigator or investigator of several NIMH, NIAAA, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID, NIAID and he tells jokes in all three, whose research aims at implementing and disseminating scalable and sustainable efficacious interventions to decrease the research to practice gap. His research foci include global mental health implementation science and the intersection of HIV prevention and care with mental health and substance use disorders among diverse vulnerable populations in the US and globally. Please join me in congratulating them. As we are so few, which is fine by me, I was just telling them, thank you, Maria, first. Maria is my sister, and she's been really part of my life. So I have, you know, Francine Cornos is here also, somebody who has been so much part of my life. So, which already tells you something that is very valuable. Find a good mentor. Mentors are what makes your career, if you're interested. It doesn't have to be just in research. Mentorship makes life so much nicer. A good mentor who thinks of you, because there are mentors who never think of you. In any event, as we are so few, please interrupt me with questions. You know, this is way loud, no? Is it better like this? Ask questions, because I know this already. So I'm going to fall asleep if I, just trying to see if I'm funny. I'm going to be looking at her with the funny jokes all the time. You see? So please, ask questions, interrupt me, and if you need to leave, please don't feel ashamed that you have to leave. I told the story that I went to a presentation, there were a thousand chairs, and I was the only person that showed. And there were like amazing people presenting. So I know what it's like, so you don't need to stay, and it's fine. But as I was telling the group, we do global mental health. We work in places where the resources are very, very minimal, like in rural areas of the U.S. sometimes. And resilience is what makes us work. Well, this is resilience. We will survive this, and we are good. It's better to have a few very good than too many that are not. So how do I begin thanking people? Like, number one, I have to tell you, I, more? Okay. Number one, I have to tell you, I love my life. I love what I do. This is exactly, I couldn't do anything different. I enjoy it, and I work with people that I love working with. And there's so many that I cannot tell everybody, but in that group, there are. There's a lot of feedback. I know, but he asked me to move it. Oh, I see. Yeah. You know better than I do. What's that? Because there's feedback. There's feedback. But I think it's the room that is complicated. It's in all the walls. Yeah. So, and so these are all of them, and in green, I put what are, quote, unquote, my children, people that I have trained in research. Andres, I hope that you're in green, too, now that I think about it. Maybe you're not, but hey, let me move on. So not to be ashamed that I probably didn't green you. I think that part of what I'm going to be talking about is we are in several crises that we can think of, right? You know, we had COVID for a few years. There are places where you have humanitarian issues taking place every second. You know, the suicide rates in many parts of the world are going up. There are crises. And for me, crises are opportunities, not only to investigate, but actually to do something to transform the system. Because we learn from those situations, and it would be a pity to just learn for one situation instead of trying to figure out how to strengthen the system. So in a way, I like thinking of systems. So, OK. However, as you know, change is not easy. So a little bit about me. So I'm from Venezuela. I'm actually also Brazilian-American and Spaniard. I'm looking for a fifth nationality. Anybody can help me with that, please? That makes me an international medical graduate. That makes me a Latino. I also happen to be gay. I happen to be Jewish. And I'm white, so I don't look Latino. I don't know what I look like. And my accent confuses everybody, which sometimes is a passing thing because they think that I'm one of them. And then they tell me the most horrible things about Latinos. And I'm talking attendings with patients or colleagues, about other colleagues. And then I says, te acuerdas de mi? I speak Spanish. I'm Latino. So it's very interesting. In one hand, I also get excluded from my groups. I remember I was doing an HIV mental health conference, and he was in Yom Kippur. Not only that it was Yom Kippur in LA, but when they saw my name, they were asking, why is a Jewish white old man, this is 20 years ago and I was already old because of Milton, doing a presentation in the Latino conference? And they wrote to me, it's like they have been at like 50 emails, complaining, I said, don't worry, I'll deal with it. And I just put my name at the beginning. I didn't put anything about me. And I said, I think some people have questions. And I used the opportunity to know that among Latinos, there are many varieties, there are many of us. There are many of us who may look one way, may have a different name. And that's not only with Latinos, that's with African-Americans, you name it. The variability, nobody can box any population. And we tend to do that in many ways. We're very binary in the way that we think about the world. So I just told you some intersectionalities that I have had to deal with. I don't want to tell you the questions that I was asked interviewing for residency because they were the most inappropriate in the world. Can you work with women? Can you work after 10 PM? Yeah, I'm Latino, but I can. So all of these things, and why bring intersectionality, it has affected me. I have managed, but intersectionality, which is when you have a combination of things that make you not have opportunities, that make you not be able to do what you should or could be doing, when they're together, it's much worse. And the word intersectionality that has been for a long time being used, it's only recently coming up in health and mental health as something that we need to look at to understand where we're at. So in my career, I've had my clinical experience where I saw the disparities. I saw the intersectionality because I began as an HIV psychiatrist, yes, very old, when there were no medications for HIV. Francine and I were playing together around that time in the world. And the disparities that these individuals were going through everywhere, not just in health or mental health, social services, everything, it was so complicated. I always would say that when they would come to see me for any particular reason, HIV was problem 17. It was not the most important problem. There were so many other problems that were much more important. And that taught me a lot about who we play with, who we work with, who we're trying to help. And that led, because I was working in this area, and I realized I wanted to change the system. I was in charge of a, there was an HIV clinic. I was the mental health director, and I wanted to change the clinic to be able to provide more care. And it was not happening. You know, the mental health providers, they wanted to do weekly sessions with their patients, which is the private practice model. And there were 5,000 patients. If you know a little bit about HIV, about 50%, between 20% to 50% may require mental health support or substance abuse, et cetera, et cetera. And if you have 12 providers seeing weekly, you see like 5% of the population. You don't see who you need to see. And I tried to change the system. I improved how to see people quickly. But when it was time to change what treatments, it wasn't happening. So I decided to visit one of my mentors, Francine, and said, help me. And that's how I became a public mental health researcher, which is what I'm doing. And along the way, I learned from many people. And for me, there's one thing that I have learned about psychotherapy is you have to learn how to listen, right? You don't need to be brilliant and have an answer. You have to have listened so you can consider, so you can think and move things forward. Otherwise, it's boring. OK. So in coming from being a clinician and always being a clinician and always thinking that training the next generation is super important, and at the end, it's not research for research. It's research in how we can implement it, how we can change services. So those are the three things that have led me in my research career. And in green, you have the capacity building grants that I've been part of, one that I've been at PI, New York State Psychiatric Institute, for many years. Then I had to contact my sister, Maria, to be able to create the T32 postdoctoral fellowship in global mental health. And so on, with Maria, another one in the T43, and then another one with other people in Asia-Pacific. For me, you guys, the young ones, are the most important generation. If we don't pay attention in how to nurture you in the right way, we're not going to make any changes. And then these are some of the research studies that have participated in BOLD are the ones that are studies that I have been the principal investigator. And as you can tell, I work in many areas. In the US, globally, HIV, non-HIV, substance use, all mental disorders. And what has been super interesting is that then I can combine in trying to do what is services, right? So now we have services research in New York State, and by SAMHSA, and the Office of Mental Health. And we are thinking in how we can scale up with government some of what we're doing. And I'm going to tell you some of those stories. So this is how my research career started. It's a research award, so I have to start with the research. So we did work in Brazil. So there was a group in the US. Actually, those people that I said that I was the only one in the audience, those people had created seven or eight HIV prevention interventions for people with severe mental illness. None of them, even today, is being used anywhere in the US, so there's no implementation. I decided to get them to Brazil, and we got the grant, we had a beautiful group, and I learned so much. Number one, we work with anthropologists, so what we're talking today that we need to have, you know, people from different backgrounds, team science, or, you know. We did that almost like naturally. We had anthropologists, sociologists, psychologists, nursing, everybody. And we managed to work, and I knock every door, as people may know me, I knock the door at the person in charge of mental health in the city, and talk to her, and she said, okay, let's try to work this together. So if you try, sometimes it happens. I've knocked at doors, and it doesn't happen. But what I want to tell you about this particular grant that was super important in my conceptuality, you know, in the conception of whatever I want to do, it was bringing clinical prevention research and working with patients at the same time. And back then, which was, we got the grant in 2002, there were no recipes for adapting interventions. So we were looking, okay, how do we adapt the intervention? How do we adapt the intervention? There was nowhere in mental health, in HIV, nowhere. So our grant was, how do we adapt an intervention, making sure that we pay attention to the context and the language? So this is what we created, the four steps of doing the preparation and of the intervention. So we were very aware that we needed to do optimizing the fidelity, and not just us. So we actually worked with them, and I'm not gonna go over all of these. We were very clear that it had to be a bilateral collaboration, working together to make sure that we all understand what are the principles of HIV prevention and which ones are applicable locally. We also then, the optimizing fit, which is really understanding, we did ethnographies, we had so much fun. Actually, the first day that we started the ethnography, which is when you do observations, we had two research assistants going to one of the Rio de Janeiro clinics. And unlike here, because the weather is phenomenal, you have a big garden inside the unit. So my research assistants were there, and they had a shirt saying that they were researchers, because you're not supposed to talk to them, to the patients, they have to come to you, right? And somebody came to one of them and says, you know, what research do you do? Well, we do how to prevent sexual transmitted infections, and the person says, oh, and how do you do that yourself, was what the patient said. And she was like, what? She didn't know what to do. It's like, and she says, why do you ask me that question? Brilliant answer, because you're not supposed to tell them what you do, right? And the answer was, well, because I can only have sex with people that wanna have sex with me, and doesn't matter if they're gonna be respecting me, I gotta take it wherever I can take it, where I can have it, because otherwise I don't have sex. Which tells you how the stigma of mental illness has an impact in sexuality and in relationships, and it had not been studied before, and our hope was to introduce them, and actually we created a measure. Moving on, to be able to create the intervention, we again gathered together to be able to balance fidelity and fit, to make sure that we would have every part of it in there, and then we had what we would do normally, that we had the, it's so tiny here, we pilot the intervention, and then we have the efficacy trial, right? What's interesting is that this is prior to implementation science being funded, or existing, and we were doing it without knowing it, because we were clinicians with researchers and anthropologists and nurses, we're all doing everything, how do you implement it? So we did actually implementation without calling it like that, and it was super exciting, and that led to then calling Maria, I'm not gonna say what I told her, because we're being recorded, and I'll tell you later over coffee, and we created a postdoctoral fellowship, and this is where we are nowadays with our relationships in the world, and some of them are very strong, some of them just consulting, and this is work that we've been doing, and that we love doing. What I put in, you can see that there's a fuchsia in Mozambique, and I, why I highlight is because we did beautiful work there, that now we've been able to adapt for other places, and we are doing, we brought things from the US there, now we're bringing things that we developed, adapted, and created back to the US and to other countries, so it has influenced dramatically what we do. Now, let's get to the learning objectives. What are we gonna be talking about? We need to understand the current status. I have to tell you, I need to make something, because this is so small, that I will have to be like this. For some reason, it doesn't allow me, oh, there we go. Now, so let's talk about understanding, describe barriers, and then propose a plan, okay? So let's get very sad right now, and the next part is very sad. The global mental health reality is absolutely terrible. One in every four will experience mental illness. One of every eight currently has mental illness, and if you are in situations of humanitarian war, et cetera, one in every five currently will have a disorder. If you think of the HIV epidemic, we would say that in sub-Saharan Africa, when we had 20 to 25% of the population having HIV, we called it an epidemic. We don't do that with mental health. Why? You probably know why, and the problem is the burden is enormous on health, education, work, productivity, family, and the economy. Everything gets affected by this, and what's incredibly sad, in 1990, they did the first real measurement of burden of disease. We have not changed where mental health fits in the burden of disease. So all these amazing research going on, all these interventions have not done anything to improve the burden of disease in the world, and in the U.S. too, by the way. Maybe it moved a little bit, but this is the global reality. Another part of the reality that perhaps explains this is the lack of resources. The mental health care budgets are less than 5%, and in some countries are 0.2%. Low and middle-income countries, and when they get money, everybody thinks that the first thing that you need to do is a hospital. Instead of thinking community, everybody thinks let's have a hospital, and I remember Maria and I visited a beautiful, I'm not gonna say the country, a beautiful hospital in a place that it was miles away. Nobody was there, and they needed to do so much work to bring people to do community care in the hospital. So the mentality of what we need to do, it's not thinking of communities. It's things more of severe mental illness and hospital. What we've been talking about, the pervasive individual and structural stigma and intersectionality affects at multiple levels the issues of mental health. Globally, we know that the existing mental health workforce cannot meet the demand. 50 to 80% of those in need don't receive care, and that's another part of what makes the epidemic worse. And if we continue talking about what we do, all of us do this work because we care about people. Nobody goes into this world to be a millionaire or to et cetera, et cetera, et cetera. We come into this world because we wanna help. But the reality is that the way that we provide treatment perhaps comes a little bit from the way research is created, that it's number one, and I'm not talking evidence-based intervention research. It's the research of looking at diseases one at a time is one problem. And the other is that we offer the same thing to everybody and we treat disorders. We don't treat people. So instead of trying to understand your comorbidities, we are trained no matter what to train a disorder that you have. For severe cases, you know what we do. We hospitalize, we may use the emergency room, et cetera, et cetera. But the rest of the population in outpatient gets most of the time one-on-one. People don't know how long they're gonna be in treatment. Nobody says to you, except if you're using an evidence-based short-term intervention, how long you're gonna be in treatment, which is, you know, how long am I gonna see you? The expectation that we have of the private practice model into the public health model doesn't work. So we don't have a public mental health lens in the services that we provide. And just to add a little more, and if care is available, access to care barriers are common everywhere. I know that I'm making you very depressed, but it's the reality. Wait lists are really long. And we don't do early intervention, right? Because if I have to wait six months, we've seen instead of catching me when I am a little depressed, you're catching me when I'm more suicidal, et cetera. You understand what I'm saying. The treatment options, as I said, tend to be long-term. Very, very few systems of care use short-term interventions. And by the way, I want us to think for two seconds, and what does that mean? Only two, no more. We are so binary that we tend to think either or, and there's no need to think that way. You can start with one and move to the other for those that need more. So part of our mentality is that when we talk about short-term interventions that have been done in research, you know, trials, where you do these and then you measure for three months, and this is the evidence, the idea of moving into how do you incorporate it in a continuity of care is not there. And there's very little research in that area. It was more than two seconds. And the treatment don't match the preferences. And how do we know this? You know, Mark Olson did this evaluation of the data, how long people stay in care. And 60% of people drop out between sessions three and five. You know, boom, they're gone. Short-term, right? They have a short-term stay with us. And we have no idea why, because this is just data collected from insurance, so we don't know. There has not been, you know, qualitative data. And the task-shifting approaches, which is, of course, now you understand that I'm gonna be talking about, are not common, especially not in our country. And by the way, the median number of sessions globally for mental health is, guess. One. Okay? This is what the world. So I talked a little bit about this, so I'm not gonna say, you know, I'm not gonna spend too much time in, but there are social determinants that make the intersectionality happen. I'm not going to read them, please read them. And it's very important for us to know that even in AI, but by the way it should not be defined as artificial intelligence, it should be defined as augmenting intelligence, and this came from people talking yesterday, because it's again not either or. Can we incorporate it in a way that we make sense and learn more from access that we have? However, that access has also bias, because who can enter data are people who have certain education, certain ability, they have fingers because they're not amputated, they're not cognitively impaired to be able to write something, so even the data we are sort of like creating the same system that doesn't allow for minoritized, vulnerable people who don't have money, don't have Wi-Fi, like in Mozambique, you know, who's gonna be in Mozambique participating? Yes. Can you use the mic? Because they want me to do that. No, I don't mind you asking, that way, that way, that's a little bit of coffee for my talk. Well, hi, I'm a medical student at Torrey University, and I was at the talk yesterday, and you were mentioning how we have bias into this artificial intelligence, right? And I don't know if you were there, but they were talking about how, if you're not at the table, you're the menu. Yes, I was there. I guess, are you at the table? I am. I'm trying, and I'm getting more and more and more, even if there's somebody doesn't want me to. Good, because I guess like my question to you was like, what are you at the table doing for this artificial intelligence, so I'm sorry, I think we're supposed to call it something else. Augmented intelligence. Augmented intelligence to be offered more accessible to this community. I will answer that later on, but remind me to answer that, because it's very important, the question, and I want to learn more, if you, if anybody can help me more, I'm eager to listen to figure out what else can I do. Okay, and there's also the sociocultural and systemic structural factors that affect how people are assessed, how people are given diagnosis and treatments, and it's very important for us to understand that that's the real world. So what's the impact of this intersectionality and social determinants that I'm talking about? You know, once diagnosed right here in the U.S., minority adults are more likely to have severe and persistent courses of disorders than white adults. Suicide disproportionately affects American Indian, Alaskan, Native, and rural populations, as well as sexual and gender minority populations. So it is a reality that it affects how mental health develops and continues, and it exacerbates other disparities, social systems, education, social services, carceral systems, which in turn worsen health and mental health disparities. And we talked about the burden, right? In a way, this explains how the burden of disease is so complicated. So let's talk about barriers, as if I have not been talking about them. So when we think of us providing clinical care, you have a patient and you have a provider. Of course, at times you may have a family, but this is simplified. And that's where we do the clinical activity. I'm going to put short-term intervention there, because it's something that I want you to start thinking more about. However, this is within an organization, could be a clinic, it is within a system, a structure that has policies and guidelines, and it's completely affected by the context, their general policies, funding, the poor access to care, events, worse access when these events are taking place, and community intersectionality that I just talked about. So when we talk about the beautiful interventions that we produce and don't think of all of that, we're actually not thinking enough, because we're not going to implement them just by creating these beautiful interventions, which I love them, by the way. Nothing wrong and bad about them. And this is how we do research, right? You know, we go from basic safety, efficacy, effectiveness, and then we go to implementation science to try to figure out how to even help with the effectiveness. And with that, there's some hybrid work that can be done. But this is the funding, how it goes. Very limited funding for this, which is how you use what we create. And then to be used in the world, it's even worse, which is their models, strategies, and frameworks that we have in implementation science. But unfortunately, we use language that nobody understands. So I'm also being a little bit mean to implementation scientists. We talk in a way that people don't understand us, and we need to simplify the language. By the way, I published this, so it's not that I'm just doing it in this room. It often addresses one or a few disorders at a time, because that's how research is done. There's minimal funding and time limited. There's something about the usual way of research getting funded, which is, you know, you can be given, if you have a trial, you can, five years. And you come up with a way of testing it and measuring it in five years. If you're trying to change a system, if you're trying to see how it works, there's no way that you can do it in five years. And there are not funding sources in NIMH for the continuity of these things. Even we had global mental health grants. Nothing more after that first grant. There's no way for the continuity. We're talking systems. We're not talking an individual in a disorder. And there's scant scale-up studies because of that. Because at the same time, you know, and I'm not gonna be critical of us, but I want us to balance reality and research, which is, we create things. Hold it. Do you send your children to school? No? Have you done a randomized clinical trial with a school that you're sending your children to and what they're being taught? Yet you send them, right? Because they need an education. And I'm not suggesting that we don't need to use evidence, but there's this huge way of thinking that if it's not completely, perfectly researched, then we cannot implement it. But in the meantime, let people kill themselves, you know, etc, etc. So there's a way of thinking of our research that we need to do adaptive designs and longer designs to be able to look at this. I'm not advocating for not doing, not bringing research to practice. I just want to put a lens of understanding. And as I mentioned, the scalability is terrible. There's very limited funding and the evidence-based interventions rarely make it to practice, except for some medications, psychiatric medications in high-income countries, or for example, antiretrovirals in Sub-Saharan Africa, because there's dramatic funding from PEPFAR to provide that and, you know, global funding, not just from the U.S. There are successes. There are some systems, you know, the Veterans Hospital, they use short-term interventions. But is anyone ready to pay for the cost despite the benefits? You know, can we really invest in these knowing that there's going to be a benefit? So let me talk about the benefits. So we are a little bit more talking about good things. First, I want to remind ourselves who we are in the audience. There's some of you who are clinicians, some of you that are researchers, and I'm going to talk about the clinical ones. And this is how the clinicians and policymakers think of, and it's not perfect, this is just some little notes. Initial intake and regular follow-up sessions is what happens in treatment. There's several axes, several diagnoses. The length of treatment tends to be undefined. Patients pay depending on insurance, right? Some people have access, some people not. There are long wait lists. And when does the treatment end? Sometimes people don't even know how long they're going to be in treatment. This is how clinical research works. There's a baseline assessment and follow-up assessments. However, there is an eligibility criteria. One disorder, perhaps two at a time. Very long assessments. We pay them to support, to allow us to ask them so many questions. And by the way, in many countries you cannot pay even for assessments and people participate in research. It's measurement-based. Again, very long assessments. There's no way for you to know what is it that you need to ask. Participants are providers of reimbursement in research, which is not sustainable. You can only do the research. You're paying, you're paying, you're paying, you're paying. Research goes, boom, everything goes. So there's no infrastructure change. Anywhere between 3, 6, 12, 18, 24 months, and I'll put the numbers smaller because most studies don't go for such a long time. And it's not designed for clinical practice. Again, it's very hard for any one of us to use it based on what I just described. So this is where implementation science comes into the picture, where you have an ability to, number one, look at patient services, implementation level outcomes. You use task shifting, and I'm going to explain in a minute what's that. You use evidence-based care, so we're still doing research, things that have been tested. We use stratified care. We can use measurement-based care. All of that is possible. But we have found a way, or are trying to find a way, to make it that it's actually feasible to be able to do and bring the research, the research to the practice. So that's what I'm about to talk about today. That's my goal of today. Task shifting and sharing. What we do is we have a trained and supervised mental health... trained and supervised by a mental health specialist. We have non-specialists doing the work, and I have to tell you, there's research in multiple countries showing the efficacy of this. You have nurses, case managers, non-clinical staff, navigators, peers, college graduates, students, high school and elementary school graduates that can do this work. You don't need to be us to provide a short-term, well-trained and supervised treatment. And is it effective? Yes. Multiple studies looking at that. Cost-saving? Absolutely. The cost and length of training new mental health providers. Remember how long it took some of you to get trained? How do you train enough people for the need? And it's very expensive. And is it ethical? I think it's more than ethical. You have something that you can use and you're not using it. So the question is, is it ethical that you're not using it even though you know that it can help people? So that's a one of the things. But importantly, there has to be trained and supervised. Some of the things that I know Fran and I saw around the world is that many people get trained to do an intervention, and because they are not supervised and there's no way of monitoring what's taking place, people do whatever they want to do. And they do it with a good intention. Nobody does it wanting to hurt. And some of us, you know, you know CBT, you use a little bit of this, you use a little bit of that. But you don't really know that you're using the evidence. And I'm not gonna ask any of you to raise your hand if you do that. But we saw the implications of not having real training and monitoring and supervision of what's taking place because it dilutes the evidence. So how do we train? Because you're saying to me, Milton, well are you gonna be doing the same? Well, our way of, the model of our training is we have a rigorous training that includes didactic and experimental, experiential, I'm sorry. So every person has to have three cases under supervision to demonstrate that they have the skills of the intervention that they're being tested. And we're using it for rapid valid assessments and triage. And we're also using it with three different evidence-based interventions. I'll show you. However, we maintain, we sustain the monitoring ourselves. And if there's somebody within the setting, which could be primary care, mental health, we train a supervisor to be able to do that work. Because we don't want them to need us. We want them to be able to do this on their own. Only providers activities are supervised by site-based clinicians, trained and supervised to ensure rigor and sustainability. So this is our training model. We've added to this, which I'll show you in a few minutes, technology to make sure that the rigor, it's there both for the training and for the provision of care and for the supervision. But I'm gonna tell you a little bit about Mozambique, which is behind all of this. Very, very poor country. 30 million people. Right now they have 22 psychiatrists. When Maria and I started there, they had 13 psychiatrists and there were 28 million people. There were 125 psychologists working in the system of care. They created, task-shifting on their own, psychiatric technicians. And they had one in every city. However, only in district areas, in urban areas. Nothing in the rural area. And Maria and I started working there and, you know, one of our fellows was the director of mental health for the Ministry of Health, which is a fabulous thing to do, to be able to do, because then you can try, figure out how to have impact. And she needed to do her PhD in a pilot. Everybody else was doing, oh, I'm gonna look at depression, perinatal. I'm gonna look at HIV, and she could not come up with a pilot. And I had to sit down with this, like, Lydia, you need to get your PhD. You're in charge of mental health. You cannot be the only person in the group who doesn't get her PhD. Says, Melton, I cannot do a little thing. We need to do something for rural areas, and I cannot do one disorder. I need to do all disorders. And I said, oy vey. And Maria said, oy vey. We're New Yorkers, so we say oy vey, regardless of anything. And, but, it was an amazing challenge to try to figure out, because policymakers were interested. Clinicians were interested. Community health workers were interested, because they had done a little bit of epilepsy work in rural areas, and they were so excited that, finally, medications for epilepsy were being provided in rural areas that had not been given before. By the way, 70% of the country is rural, so we're talking most of the country. And when the community health workers and advocates saw that they could improve epilepsy, they wanted more. So we were very lucky that we walked in in a momentum of phenomenal opportunity. And we've done more than that, because they are so incredible, and our teams in New York, UPenn, at Columbia, UPenn, and in Brazil, there has been such an amazing opportunity to create. I'm not gonna tell you everything, but these are all the activities that we're doing that are research-based. These are not even scale-ups that are happening, and continue to happen, because there is a need, there is a wish, and there's an investment. And, by the way, so far, the ministry has not given us one penny. So we have been able to do this with research money, but, of course, you're gonna tell me, Milton, there's no way you can scale up in the country with research money, because there's not enough money to do that. That's our next adventure, and figure it out. And we're trying, and maybe in a year, I'll tell you more. How this worked was because we have phenomenal researchers, we have the ministry, we have communities. So the community of workers in each rural clinic are part of, also, an advisory board of each clinic. So the understanding of what's happening in every community, it's part of what you do in the system. So, brilliant. We don't do that over here. So for us, it was so easy to ask something, and, you know, the town was represented, because ten families have one leader, ten leaders have one leader, ten leaders have one dealer, and then they have the person who is there. So it's not even by election of one person, it's by, you know, it's a beautiful way of determining who's going to be there. And our goal was sustainability, sustainability, and sustainability, because we didn't want to do something that, when the money was out, would be gone. This is what we've accomplished. We have 10 master trainers and three different evidence-based intervention. Then we have 25 trainers and supervisors, and it's growing by the minute, probably they're 30 by now. We have 19 co-trainers and supervisors, because we're only working in one province. So we have trained all the psychiatric technicians of that province to be trainers and supervisors. We have trained 300 primary care providers and 600 community health workers. They as I mentioned, the competency and how we do it, so we added 949 providers. There were about 10, there were 21 before. I'm sorry, there were 49 before, we added 900. Our training is now part of the regular training of mental health specialty all over the country, and the Ministry of Health and one university so far are participating in this. So every mental health clinic uses our work, and also every HIV clinic uses some of our work. So she said to us, all disorders. Is that my phone? I need to move on. I'm talking too much, I'm enjoying it. We needed to do all disorders, and as you know, if you're gonna screen for every disorder, you will have 99 items, right? So who's gonna do that? We met with the director of community health worker for the country, and I asked him, how many items can we ask? And he said three to five. 99, three to five. So we know Melanie Wall. I went to Melanie, a phenomenal statistician, biostatistician, and I said, can we do this? He said, you're absolutely crazy. Can we do start with three and then move to more? You're absolutely crazy. She didn't sleep for a week and came back with an answer. So you have the comorbidity there. Look, you know, you can look at suicide, it's alone, but it's also with other things, which is what Maria was talking about this morning, right? You know, you have comorbidities, and by the way, these are common mental disorders. So in this common mental, in the gray, you include depression, anxiety, and PTSD. Then substance includes all substances. So in this population, we had a variability that, how do you evaluate all of that? So we need to screen, identify in multiple settings, and triage all disorders to the appropriate level of care. So we managed, believe it or not. We had this amazing opportunity. We decreased 99 items to three items to identify any disorder. It's been validated in Spain, in New York, and South Africa, besides Mozambique. Then we add ten more items to categorize between severe common substance use and or suicide. And again, it's an or because the comorbidities are high. We use a statistical method to reduce the number of items, but we didn't want, especially when we ended with three, Maria and I were thinking, are we nuts? Can three items go for any disorder? So we actually were nuts, but we met with anybody in the institution who does depression care, regular clinical care, as you know, people who know us and are in the audience, and we ask everybody, are these questions good enough? And they are like, unbelievable, yes. They actually do what they need to do to identify somebody. So we have 90, let me show you the statistics that we have in here. So we have for any disorder, in Mozambique is 94% sensitivity, in the U.S. is 95% sensitivity, so I can identify any disorder with three questions. Then we were looking for high sensitivity. We don't want to miss anybody who may be positive. We can always ask more questions for false positive, but we don't want anybody to fall through the cracks, because we also want to do early intervention, so it's not just about being specific. We actually didn't have bad specificity, and in severe disorders is the only one that is below 0.7. The beauty was that then we did by proxy, and a family member can identify with 73% sensitivity that the other person may have a disorder, and then we just go and ask the question. So that opened, like, wow, and again, this was serendipitous, because people come accompanied to the primary care clinic. They have to wait hours to be seen. So we were interviewing you and your sister. And we asked you, how about your sister, and your sister, how about you? It was an idea that we came up because there was a proxy study actually done in Mozambique in substance use. The methods were not that great, but the good thing is that they offered us a way to do things so I listen to what's happening everywhere. It's been validated, as I mentioned, to you and for countries. So these are the items. As you can see, it come from valid measures that already exist, and they help us determine what's going on. I'm happy to work with you if you wanna use it because it has royalty. I don't charge for it. It's part of Colombia, but I'm happy to help train and figure out how to use it wherever you are. It can be used in paper, by phone, email, websites, apps, in person, self, or interview. It's been used in three countries for now. It's about to be start using it in Israel in mental health care, primary care, community care, both in rural and urban areas. In Mozambique, we used it in the hotline. The three questions within the regular hotline diverge the person to talk with somebody in the mental health line, crisis lines in a few countries, HIV and mental health scale-up efforts in South Africa are using it. And after triage, you can use it again. You can figure out, okay, you refer me, this person. You come two weeks later, like any good clinician, you would ask the questions again. So we wanna make sure that the people are positive or false positives or are negatives. And in research, we're using it too. And then, there's something that didn't show that I wanted to, well, it doesn't matter. Besides assessing, you need to provide care, right? You know, screening and referring to nothing doesn't work. So we also developed, and this is where it comes, screening is not enough. What do we do after we identify, does it need, what do we do to understand what, I'm sorry, what do we do after we identify does it need? What can we do understanding the lack of mental health providers, right? You need to refer people to somewhere. And again, we were very lucky that we were able to have many researchers at Columbia and at UPenn that played with us and understood that we wanted to bring their work to be implemented, which is a good thing for everybody's ego. Oh, I'm sorry, I'm being recorded, I forgot. So we can do all mental and substance use disorders, that's shifting, it's also step care because we can bring somebody to minimal care or to higher care if necessary. And at the same time, we do measurement-based care. We do measurements at every session to make sure that we can track monitors in a sustainable way. So we have the community mental wellness tool, which is the first three items, then the mental wellness tool as a screening, and then we have the evidence-based care that we provide. I mentioned to you the three items that leads to ask the three items to the person. So the community health worker goes into the community, can ask the questions of everybody in the family, and then goes to the person who needs it, ask the three questions. If positive, ask the 10 questions. We can categorize people in four different categories of disorders, and they can immediately start treatment, each one for each of the disorders. And it can be one first and one the other. Obviously, you're gonna tell me, suicide and severe goes first. You need to take care of that. So severe disorders go to the people who can assess and prescribe. Suicide, depending on the level, they can do safety planning intervention or referred for high level of care. And if they have substance abuse and or common mental disorders, then deciding which intervention to start with. And again, this is not or, this is either or, and you start with one. And we have learned in interventions when we do two interventions, one first and one the other, that sometimes the first intervention sort of takes care of some of what's taking place with the other problem, because you're addressing it. Sometimes no, but then we can have one intervention first and then another. And then again, if necessary, six months later. And the beauty is that it's integrated into the system, primary care, community care, and mental health clinics. We can get outcomes in our platform. I know if Andres is seeing patients today, how often is he seeing Milton? If Milton showed up, I can see if Milton's PHQ-9, because we use measurement-based care, is going better or not. I can also see if Andres, he was my student, so I can say this. And I can see if when he's using the technology, he gets stuck in a place. Everybody takes, he never gets stuck. He does it beautifully, but when I do it, because I was trained as a peer to provide it, I always get stuck somewhere. I don't need to go and tell you. As a supervisor, you know and you come to me. AI, we're getting more of that. So it's brilliant that, and I didn't know this when we started this, this is just talking to people and trying to figure out how to improve what we do. So we can train, supervise, and monitor. And then when I go and talk to you, I said, Milton, let's talk about this part of the session. What's going on there? Because you're stuck with it, or you go too fast, et cetera, et cetera. So I mentioned to you all the outcomes that we can get that are very important, and implementation for us was the core one. But then, we didn't realize that with a proxy measure, we could do something else. Community health workers have to visit each household once a year. They can get household assessments. You're getting not a perfect prevalence, but you can get an idea of what's taking place in every household. And if you do it every year, number one, that can inform you what you will need. But if you do it every year, oh, I didn't put the slide of the, yeah, I'll have it later. The, I'm gonna go to that slide because I'm saying it, and I said all of it. So if you do it every year, this is what happens. You can get prevalence, incidence, determine promotion and prevention efforts that you need to make, and where do you need to bring more efforts towards perhaps suicide increasing in this area, and trying to understand why it's increasing, and not finding it about it afterwards when you look at the data, if you're collecting data, because remember, many places don't collect data. So going back to where I was. So this platform is adaptive to multiple services and sites. It increases community early detection and early intervention. It has core competencies, because we know if you're using the skills or not. And in total, for three interventions, you need 12 days of training and six months and six cases. So totally, it can be anywhere from six to eight months to train everybody in all the interventions. It's embedded in the community, it's patient centered, as I mentioned. And guess what? The community health worker can evaluate 4,300 people a year, one, and can treat 1,400, one. Doesn't mean that the treatment is completed, but the access, and remember, people drop out between sessions three and six, you immediately can provide care, and they're engaging care. You can figure out more if needed. And so far, it's in Spanish, English, and Portuguese for now. So this is how it works, community, and at the same time, the measurement-based care that I talked about. I'm gonna move these two, because we're gonna run out of time. And this is just to show you the number of cases. In 30 community health workers started doing these assessments in 20 clinics. They visited 726 houses. They used the community mental tool for 5,000 assessments. 79% were positive to go and check if the other person had. Of course, not everybody had. It was a distribution of, you can see, male, female is nice, and age is also nice, but we were doing under 30, which is interesting for early detection, right? You wanna do early detection. And 2,600, which were 51, were actual positive with the mental wellness tool. Now we're doing, bringing these things with reciprocal learning to other places. We have it in New York State. We're having in South Africa, and also in four countries of Asia Pacific. In New York, we have funding from New York State and SAMHSA where we're doing these. These are the clinics in all the areas of New York that we are. And the idea in a country like ours where you have a larger and more well-structured system of care, the idea is that you do step care. You know who doesn't have symptoms based on our tool. Those that have severe disorders definitely need to be going to either primary care for medication management or mental health if it requires more than depression and anxiety. And then we can do low to moderate and even sub-threshold disorders because you need four sessions. So you can even treat people who may not have yet a disorder but help them in preventing the disorder becoming a disorder. So you increase access, you eliminate waitlist. You know, with New York State, we had, we were given, I'm not gonna tell the negative. We were told, we were given the money, and in three months, we were supposed to show something. Oy vey, right? How do I show in three months? They wanted, and their goal is to decrease waitlists. And we have to train people, we have to do all of that. We're going until three o'clock, right? Okay, just checking. And we're like, you know, and it was a one-year pilot. So if in three months I don't give them what they want, they're not gonna put me in the funding for the following year because that's how states work, you know, and many things work like that. In the first training of the first intervention, we eliminated waitlists. Not even the three interventions. We just trained one intervention. And because each one of the trainees needed three cases under supervision, by the time we finished all of them doing the training, there were no waitlists. So they gave me five more years because I gave them in three months what they needed. So did I expect that that would happen? Absolutely not, but hey, we were lucky. I have to say that I'm very lucky. I'm surrounded by amazing people. And so there's early intervention, there's prevention and promotion, burden of disease can decrease, and it's tailored to the individual needs. Not everybody can come every week, et cetera. And we also are looking for employment solutions, right? Actually, these are college graduates. Some of them are choosing to go into social work school or psychology. And in other parts where we do it with elementary school or high school kids, they choose mental health professions, which means we're also having an impact in increasing the number of people who are interested in our work, which is not that common, as we say. And again, it's not either or, sorry, it's and. It's not or, it's and. We can do one, move to the other, come back to this one, engage them, and determine with them what they need, and for them to be part of that decision. And I told you about the wait list. So this is the combination of things that we're doing. I already did this, so let me move it forward. No, I didn't do this one. Simplicity, sustainability, and scalability, it's adaptable, increases. No, I did do this, sorry. The impact, resolving wait list, embedded into the continuity of care, which is very, very important. This is not a standalone thing. Building a new workforce, adaptable to service delivery, and its simplicity, sustainable, and scalable, integrated with technology to simplify decision-making tools, durability of training, working with policy makers to ensure science information, decision-making tools, durability of training, working with policy makers to ensure science-informed policies, because that also... So what I can tell you is that when we started working with OMH, the people who know me know me that I don't want to do work just to write a paper. I like writing papers, it's not my main goal. I want things to be implemented. So I said to them, if we do this, we need to change policy. And this is starting to happen. There is a movement in the country for task-shifting, for community health and community mental health workers to part, and we are influencing beautifully OMH to do that, and we're very... All my students know that I say sustainability, sustainability, and sustainability. Engage everyone, listen to everybody. Everybody has a good opinion, and even tell you something bad, you understand something about that. So listen, like you do in your psychotherapies, if you do. Partner with country researchers, health system, professional associations, everybody should be invited to the party. Policy and community, to help promote and ensure policy impact. Start always with local capacity building. We researchers... I'm going to go for two more minutes. We researchers are horribly seen all over the world and in the US. The first time that I went to South Africa, there was this person that had a beautiful family where he was white, married to Indian descent, and had adopted a black kid, a gay couple, and I wanted to meet them. I wanted to see all the colours. They wouldn't have coffee with me. It was like, do I smell? What's the story? Sometimes they're funny. And you're a researcher. You're going to come here, you're going to draw blood, you're going to write your papers. You don't care about us. That was... You remember, Fran, when we went the first time and said, oh my God, I'm not going to say the word that we said? We really need to figure out how we transform how people are viewed. So talk to everybody and connect with them and train people in all the areas. Research, services, training. It's not that complicated. Oops. Saying you need to hurry up. Research should leverage existing human resources because otherwise the money that you use to pay for those resources, if your money's gone, that is gone. So you need to figure out... So in Mozambique, we didn't pay one penny for the people providing care. They were part of the system. We trained them, we provided them. We spent a lot of money in training. We spent money for the research, but we didn't want for our research to go and the treatments to disappear. Our research is ending. They're doing it. They don't need us. We want to do more because we want to scale it up, but they're doing it. Implement and monitor across time evidence with rigor so digital technology can really help with that and can also aid with efficacy, quality of supervision and provide multi-level outcomes, as I've been mentioning many times. And keep the eyes on the horizon. There are always going to be multiple barriers. Barriers never disappear. It's expected. So these challenges are actually opportunities to figure out what you can do, who do you need to incorporate, who is the person who can help you change things. And it also gives you a way to learn what's feasible and what's sustainable to be implemented. So if we think of bringing research to practice, which is the main goal, you need to involve policy community and research partnerships and end users, include them. Contextual implementation of the evidence and research to practice at scale with equity, sustainment and sustainability. Equity is the principle with the smallest evidence, unfortunately. We haven't done too much about that. Global health perspective is overcoming structural issues that we can use for the US and that's why we're bringing the work to the US. And, you know, coming from the world of AIDS, the people who are doing clinical trials and have been doing work for many years, they have the networks of researchers who do the work, who meet constantly, who present negative findings and positive findings. We don't do that in research in general, but it allows you to think of implementing and scale up because then you know we've done twice this or four times and it worked one time and that's the time that got published. So there's a way that we need to be a little bit more, have humility and look at the work that we do with more transparency. And the issue of funding, for me, it's very, very important because without any funding, you know, we need 10% of funding minimum in any of what we do for mental health services, hospitals, research. You need 10% to be done for this. Otherwise, there's never going to be... By the way, that number is not mine. It's from the Global Mental Health Action Network that they came up with the numbers to do this based on WHO work. And funding for mental health implementation research, which is, remember, it uses the same funding sources for clinical trials, five years. There's no way to implement and measure implementation only in five years because you don't have what you need. And it's not that I want more money. I want to be able to put a project and see it grow and figure out how to scale within it. Renewals of successful projects should be part of the normal part. And this is also talking to scale-up funders. You have to think of mental health. I have to tell you... How many years do we have with HIV? 1975 was when we first did the testing. 81 was when we did the testing. 81. OK, you know, I'm getting demented, so six more years. You know, mental health funding globally has been minimal. And now we're talking for the first time, we're making it the norm. How many years have gone by? You can do the calculation. How many people have died? And some of us have offered to do things for free, and they would say, no, we don't need you. So we need to transform the world. Thank you. The momentum for the impact exists. Funders, you know, you have heard it, if you're going to listen to this, and partnerships. I'm always looking for partners. I love working with other people. So I'm going to stop with that, and that gives us... APPLAUSE 25 minutes for questions. So you asked about AI. So I just heard yesterday what you heard. And I have in my team, Jennifer Mutz, it's somebody that we are looking into how to improve the technology. So we're talking with everybody that we can. I'm also... I've gotten involved in doing work in Israel in Arabic and in Hebrew, and we're doing the hotline for, you know, anybody that calls in three of the four insurance for the country. And we are talking also with the AI people who are involved in the work with them to figure out what we need to do. Is it going to be the intersectionality? I'm not sure, but I'm going to be at the table, and I think this way. You can see people in the WhatsApp writing things that demonstrate the lack of understanding of these things, and it's beautiful because they're putting it there and gives an opportunity to... ..let's talk more about this, et cetera, et cetera. But I cannot do it alone. I'm actually meeting with the two of them that were yesterday to figure out how do we do more and how can I do more at Columbia to figure out how do we impact and to have our voice included in there. I'm trying, but I don't know that... If you have something to tell me that I should do, I'm happy to hear it. Questions, concerns... You have to go to the mic. Otherwise, they're not going to let me go home tonight. So, first of all, many thanks for your talk and also for your friendship. The question is about clarifying some points. All your work you have done in Mozambique, so it was belonging to research work, and it's still continuing in this research work, isn't it? Or do you have some mental provider, mental psychiatrist doing mentorship and supervising and all this work they have done with the research team? So, to make it more sustainable, you know? No, no. Because if the research ends, then what happens later? We only pay for creating the trainings and for the technology. None of the trainers, supervisors, all of them were part of the system. They were already working within the system. So, we didn't hire anybody new to provide care. We didn't hire anybody new to provide trainings. We didn't hire anybody new. Everybody that is part of this is part of the system, and they're continuing training, because who am I to tell them who to train? So they have trained all the psychiatric technicians of the country, are using our tools. Not all the tools, because they need to be trained in something. So how they're scaling it up is how they've been doing little by little. We're trying to get funding to figure out how do we do it at a scale up. But our goal from day one was we want to make sure that when we leave, it continues. It's up to them to continue or not. And they are continuing. Yeah, yeah. And they're expanding. And they don't even tell us when they're expanding, which is like, why don't you tell me this is fabulous? Because they're just doing it. They're doing what they need to do, like any parent does for their children. They're taking care of the country, and that's what they're doing. And it's fabulous to see how they're doing it. Yes, because otherwise they're going to be mean to me afterwards. Well, amazing presentation, as always. And again, thank you for your friendship, Egan and Eiko. Wait one second, please. People that don't know me, feel comfortable asking questions, OK? And it's not only my friends that have to ask a question. No, I think as being involved for almost two years, I always have been very impressed with the work. I'm just wondering right now, moving, talking about the United States part and all the advances that have been doing within the New York State Department, if you have begun having conversations with insurance on how that will look in terms of thinking sustainability, or how this system can be really implemented in a big scale, whether actually all these trainers are getting paid by these insurance companies, also Medicare and Medicaid, and knowing that the new providence of expanding Medicaid, I think what's like pretty recently, this can be imbued in that part of mental health. Beautiful question, and I can expand because I wasn't that clear on what we're doing. So the first time that I met with the people of OMH was two weeks before COVID. And we were planning to start, and of course, we didn't start. Then we started about a year and a half ago. And in the process of starting, this is how I got in the menu and the table. We decided to do, I do mixed methods. So qualitative research, for those of you, if you're a clinician, by the way, you do qualitative research, because you're observing your patient, and you are not just asking the questions that you write down the answers. Even if you do the PHQ-Net, you see me walk, you see me react, and you're doing an observation that you, it's a qualitative assessment of who I am. So you're all qualitative researchers, even though you don't know you are. So because we do mixed methods, our strategy was the following. We knew who were the people, the gatekeepers, and who were the negative and who were the positive ones. So we decided that we will do a qualitative interview as part of research that I got from NIH to bring Mozambique to the US, which, by the way, was the first supplement that happens in the different setting than it happens. I convinced them that it was appropriate. And we interviewed the people who we knew could help us. And we did not say, are you going to help us? We just did qualitative interviews. How do you feel about all of these things? What are your thoughts? What could be the process? And in a way, we influenced what was the process. Because once, and this is a year before we got the money. So we had, I didn't have the money then. And the plan was, you know, you and you and you and you. They were already with us thinking so I could tell NIH, you only give me the money if we're going to do something. Can we have a meeting with all of the people that need to be here? And they were in the meeting. And we knew who felt one way or the other. We invited everybody, don't worry. It's not that I was only inviting the good ones. Because you need to hear from the bad ones. They cannot, bad ones, the ones who are against. Because they can be your worst nightmare in what you're trying to do. So engaging them is important. And we engage them with difficulty, but we do. So that's one way. And the process, Andres, was the most important, most of the money that we get is to pay for the salaries. Different than what Jordi just asked. I have to pay for the salaries of these community wellness workers that we have. And the challenge is that I cannot pay for the whole state. It's a lot of money. So the challenge is how do we get Medicaid and Medicare to pay for it? And it's gonna happen. They're finding the way to how to categorize it and how to do it in a way. And by the way, this has also happened federally because we got the SAMHSA grant, that it's this, with Espaillat being, who's in District 13 in New York City. And he got excited that something like this could happen, that he could bring, and for politicians to bring, when he heard that some of our wellness workers who had college degrees were thinking of becoming mental health specialists, he was like, this is amazing. He didn't even think that, I didn't even know that that was gonna happen. So then he is getting together with a Republican to try to figure out how to bring that to Congress. I don't know when it's gonna happen, but, and there are other people in the country who are also stimulating this process. This is not just us. But the goal is definitely to pay for the services in a way that makes sense, because otherwise it's not going to happen. So the two questions are high country versus low income country. Yes, please. Hi, my name is Victor. I'm a medical student from Brazil, and it's so exciting. I speak Portuguese, then. No. So exciting to see your presentation. And one question that I had was, what were the biggest challenge that you saw when implementing this project in Mozambique? And the other question is, it seems, if I understood well, you created a new questionnaire to try to triage the medical conditions. And did you test that questionnaire in many populations to see if there were differences in sensitivity and specificity? And yeah. Sure. Great question. So I'm gonna start with the second one, and please remind me about the first one after I finish. So we, to develop the measure, we worked in large clinics in Maputo, and we had 1,000 patients that we recruited from different parts of the city. We developed the measure, and then we went to another part of the country that is very different, and we validated it there. And that's when we said the measure works. We've done this in other settings, not only in Mozambique, in South Africa, in Spain, and in New York. And the way that we validated is not just asking those 13 questions, but we put other measures. So if we see, for example, this is not that, use the mental wellness tool. This is more about, does it really work? So we put all the other assessments in the research portion. And if we see that we need to move an item, either to be one of the three, so for example, in South Africa, one of the substance use items to be on top, to increase the sensitivity. And so far, that has been the only change that we have had to do, but we don't mind the fluidity, as long as we put enough to be able to look at it. And now, for example, that I'm working in high-income countries, people want to make sure that we can do eating disorders, which in Mozambique, we didn't include. And OCD, we didn't get any case with OCD in the clinics where we were. So there's room to develop and to grow. Unfortunately, there's no money for, we have a similar measure for our lesson. We have not been able to validate it because we don't have the money to do it. I'm looking for a funder, any private funder who wants to give money, please give us money. Even in the US, I want to validate it here, and that could be so helpful, but people hate researchers, and researchers don't give money to researchers to do this, because in many clinics, they hate it. Second part of the question, or the first one. What are the most challenges that you're facing in the project? Well, I just mentioned one of the challenges, which is, number one, who believes that what you're doing, that sounds crazy, is correct. So we have had grants, for example. So I'm gonna tell you the research and the clinical, and where they said, this is impossible. You cannot do this. You know, there's the data, and yet they say, so they want me to actually lie and say that I'm only gonna use the PHQ-9 to be able to just do an intervention, and then ask the project officer, or ask for a supplement to do more. So it's a complication, and they may be hearing, and I will never get funded again. That's another story. There's always, you know, like in every, just think of every place that you have worked, you have studied, there's some people that are gonna be creating a negative environment for you. We have had previous mentors who get very upset that they're losing you, that they're not in the power of being there with you. And narcissism, both healthy and not so healthy, are part of the real world. So our difficulties have been with people who feel that, who are not listening to what we're really telling them. But we find a way, you know. So far, you know, the fact that the director of health, of the Ministry of Health, met with me and the team, and is hoping to ask more money. We were able to do it, and it was by showing the work. It's also not just, let me tell you, let me tell you. When they saw that we trained 600 community health workers, that people are getting what they need to get, it was like, wow. So you need to show, it's not just saying I can do this. It's gonna happen the same here. I need to show before. But it's not that it's that different, you know. These interventions, the good thing, have been used in many different places, and when some minor adaptations work very well, so. And I wanna do it in Brazil. We have it in Portuguese, by the way, everything. Because Mozambique is in Portuguese, yes. Hi there, Samir Sardar. I'm a third year psychiatry resident in Chicago at Rush University. Thank you very much for your talk. Thank you. It was very pertinent. I'm doing some task-shifting work with the refugees. Speak a little, you're almost like a New Yorker, speaking really fast. Speak a little slower. I'm actually from Atlanta, so I should slow down. I'm doing some task-shifting work over there with the refugee population. And one of the struggles we're running into, especially from the pilot standpoint, is with that stepped care model, and thinking about the ones where we identify need, and they need to be escalated to a psychiatrist to see. The challenge is using the system as it is. And so I'm curious, what role, if any, do you see something like collaborative care or integrated care playing in addressing the more acute needs or the more severe mental disorder needs of the population once the increase in identification of the need is actually done for the population that it's working with? Great question. I think you're also giving part of the answer that I had not finished giving to our Brazilian colleague, which is we're having many difficulties here in New York to incorporate this. Even in the clinics that we're working with, it's very hard for them to conceptualize this as their next opportunity. So for us, the biggest difficulty is exactly what you mentioned, because I'm eager to, you know, we're going to primary care clinics, we're trying to figure out how to get patients where we can do collaborative care. I'm trying to influence the hospital and the medical school, which is not easy, but the biggest problem is the structure. In high-income countries, you have so many silos and everybody's protecting their self and the money. And, you know, and if I see the patient, maybe the patient will not be a chronic patient, then the Medicaid money that this patient will bring will not come because you're only going to treat them for four sessions and then see them again in a month and maybe again in another month. So there are many barriers, but because it's not yet financially feasible for these institutions to do it, then the administrators are never going to think of us, because it's not what they do. And because it's complicated, people say, oh, this is lower level care. You know, there's all of these other barriers in high-income countries, because supposedly you have access to other care, another barrier, I'm sorry, that, but we have to go there. We need to continue. And again, I do think that we need to unite ourselves. We don't have a method of knowing who's doing what and integrating us to learn together, you know, because you might have managed one thing that I'm maybe facing and I have no idea because it's not that you published it because they don't publish these things. So there's a lot of lack of ability to understand how to deal with the infrastructures and the processes. Why I'm going for government? Because I want them to change the policy. So then I don't need to convince anybody. And that's why we went there from the beginning. Go ahead. Hey Melton, thanks for the nice talk. I think, you know, the biggest challenge is psychiatrists as well, right? Because there's a lot of issues around liability and safety. And when you talk about these things, the first reflex is always, oh, but patient safety. But I think you have proven and other people have proven again and again, it's not a real concern. But I mean, you have been with the APA for many years. In fact, you have been the founding member or founding father of the APA caucus, Global Mental Health Caucus. You know the APA well. What do you think the APA needs to do to actually like what structures, what committees need to get involved? You know, is it a resource paper? Is it an action paper? You know, what needs to come from the APA to advocate on a federal level for more funding and for these things? I love your question. Let's write it. So you're right. I can tell you very quickly, because I want to make sure that I give time to you. In the world of HIV, we were using a lot of motivational interviewing to either deal with alcohol and drugs, which by the way, we showed in a treatment when we used to call it dependence. We were able to treat dependence one session. But then we realized adherence to care and to treatment is a very important part of HIV care, right? You know, if you stop the medication or you take less than what you need to, and there's gonna be a very beautiful presentation of antiretroviral care and prep that we're gonna be having. So clinics, you know, have like the psychologists or the social worker who does this work and nobody else is involved. So we decided that we were gonna train the whole clinic, including the maintenance people, everybody, the secretary, in what motivational interviewing is. How do you, if somebody asks you a question, how can you answer in a way and learn the process? Our biggest, biggest barrier were the mental health specialists. They did not want this to happen. And on the other hand, with the other things that we're talking, I said finances for the clinic. We mental health, private practitioners or hospitals think that if we do what we are proposing, that somehow there's not gonna be a salary for psychiatrist. Part of what will happen is the private practice will always be there in places where private practice exists and gets maintained. I also think that, unfortunately, it goes beyond what we do. We're the only specialty in the world who we decide, yes, I'm gonna treat this patient or no, I'm not treating this patient. They call you from the ER, you have a bed and you say, no, no, no, it's not a good person for my unit. A clinic, this idea that we have the ability to reject a patient, they have a disorder, we're the specialists, we should treat it. Surgery doesn't do that. Internal medicine doesn't do that. You're pregnant, you're about to, no, I'm not taking this. We're too full to be able to take another baby tonight. So there's one that we actually wanna treat the cases that are easier, that are not so complicated and again, I know that at times we wanna protect the unit so it's a, but we need to think of something else and the fear that they're gonna lose money and they're gonna lose their positions. What they need, what we all need to understand that we have an ability to be better trainers, to be supervisors and to take care of the difficult cases and supervise them not so difficult. That would, and that's a huge barrier and you're right, it's everywhere. Yes, whether enough mental health specialists. When you don't have them, there's no barriers like that. Yes. Hi, my name's Pranav and I'm an incoming child and adolescent psychiatry fellow at Columbia. Fantastic, welcome. Thank you and I have a two part question. One is, have you been able to train child and adolescent psychiatrists in Mozambique and the other part is, what are some of the unique barriers to scale up your model to reach children and adolescents in these parts of the world? I think you're gonna have to join the group when you come, thank you. So, in Mozambique, we developed the measure. We have not been able to validate it because we don't have the funding and we have trained, we have great collaborations with Brazil, so we did PhDs in Brazil for a period of time and actually some universities in Brazil. Actually, now we have the first child psychiatrists of Mozambique, there's only one. Okay? And with a team in Brazil, we're figuring out how we create a team to work with and they're gonna be other child psychiatrists trained but it's one at a time, it's a very, very low process, very short process. There's only 22 psychiatrists in the country. We are moving forward to work with people who have funding from HIV to figure out, because they already do work with children and adolescent, to figure out how do we incorporate at work with them and to train psychologists who are already there. So, our first entry point would be with psychologists to be able to be the trainers of the lay people who would be involved in that. In the US, I am in millions of communications with people to figure out which clinics we can work with and where to validate the measure. I make three phone calls a day to figure out who else can I talk to. And there's somebody who got a PCORI in Columbia that it's becoming eager to incorporate because they do eating disorders. So, I said, oh, we can do the research of adding eating disorders into what we do and they know that in eating disorders, if you don't think mental health or wellness, you're like crazy. So, we are gonna be, and when you come, we can talk about methods that you can be involved, absolutely, but it's not easy. We're very siloed and everybody's very busy and everybody's like, no, I don't wanna do anymore, I don't wanna do anymore. But we have to. Well, I think that we have two more minutes. You had great questions, even though I didn't prepare the questions for you, even though they were my friends, I promise. And as you can see, we're just a few. This is not the movement of psychiatry. So, we need to write something, right? You asked a question about influenza. I didn't answer your question about psychiatry. I was part of the Global Mental Health Caucus. I don't feel I can be part anymore because I don't think that they do what needs to be done and I felt that my presence was not necessary for the goals that they had. Beautiful people that do wonderful things, but it's not what I wanna do. And it's not about this. The APA has a higher number of private practice people than services people, than public mental health people. So, you're talking about an organization and I know that we have a past president here and I'm not gonna ask her to say anything, don't worry, but it's an organization that it's for psychiatrists all over the country. The process of educating them has to happen. And I think that it will happen because after COVID, we have a different mentality in the country, which we had it before, but the problems were there before. So, and some of us are being part of what could change. I don't wanna say things that I cannot say, but there's gonna be some change and I'm happy to write a paper with you about that. If you wanna lead it, I'm happy to write it with you. Okay, go to other places. Thank you.

global mental health

low-resource settings

Mozambique

task-shifting

community health workers

mental health burden

structural stigma

sustainable practices

early intervention

policy change

scalable interventions

public mental health