Hi. Good afternoon. Thank you all for coming to this panel. So my name is Bashan Davis. I'm a program director at NIMH in the Office of Disparities and Workforce Diversity, and my role primarily focuses on minoritized populations mental health research. So today we have a panel that we titled Cutting-Edge Mental Health Disparities Research, Current State and Future Directions. If I could rename this presentation, I would have called it, you know, the State of Social Determinants of Mental Health Research. And so our goal with this session was to highlight, you know, conceptual frames for social determinants of health in mental health research by having folks present on those models as well as applications of models of social determinants of health. So today we have two panelists that will be highlighting their work. First, we have Dr. Leslie Adams, who's an assistant professor in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health. Dr. Adams has research interests that explore the intersections between gender, racism, and public mental health outcomes among people of African descent, with a specific focus on improving the mental well-being among black boys and men. She is currently funded with an NIMH K23, K01, sorry, K01 that she will be presenting on today. I also want to introduce Dr. Margarita Alegria, who is the chief of the Disparities Research Unit at Mass Gen Hospital in the Mongan Institute. She's also a professor in the Department of Medicine and Psychiatry at Harvard Medical School and has a very extensive, like, history of publishing in the social determinants of mental health research space. Today they will both present on their research and also conceptual models of social determinants of health and how they can be incorporated in mental health research. So before they get started, I just want to highlight NIMH's, or NIH's perspective, rather, on social determinants of health. So recently, the National Institute of Nursing Research actually put together a research coordinating committee focused on social determinants of health, and the way that they've sort of operationalized social determinants of health within the NIH frame is that social determinants of health are the conditions in which people are born, grow, learn, work, play, live, and age, and the wider set of structural factors shaping the conditions of daily life. As you can see here, we have some social determinants of health listed, including education access and quality, economic stability, health care access and quality, neighborhood and built environment, as well as the social and community context. Ultimately, within our NIH frame of social determinants of health, we view these as factors that can both improve and also serve to be deleterious to people's mental health and health outcomes. Within NIMH, we are beginning to define our interest in this space more, but we are also interested in learning from the extramural research community in terms of what they think we should be considering in terms of social determinants of health and mental health research. So right now, we actually have a request for information that is published that closes on May 30th, 2024, titled Moving Beyond Individual-Level Determinants of Mental Health to Address Mental Health Disparities. And so our goal is to collect information from the extramural research and advocacy communities to learn more about how we can address gaps in identifying determinants of mental health and health disparities that are beyond the individual level, as well as developing culturally responsive multilevel interventions to address mental health disparities. I have a link here, but also if you search these words in Google, this will be the first thing that pops up. I checked it today just to make sure. Additionally, another part of our strategy to address social determinants of health within NIMH is that we actually have an upcoming workshop focused on discrimination as a social determinant of mental health disparities. That's going to be on June 6th from 10 a.m. to 5 p.m., and registration is currently open. If you Google this as well, it'll be the first thing that pops up. Unfortunately, I don't have the QR code. So with all that said, I just wanted to sort of highlight what our interests are in this area as an institute, but my perspective is that the most important thing for you all to see is some of the research being done in this area. So I'm going to hand this over to Dr. Leslie Adams to present on her research. Thank you. Hi, everyone. Can you guys hear me okay? I feel like I can. All right. So very happy to be here, and thank you to Dr. Davis and NIMH for this invitation. I'm trying to figure out where I can put this where it won't spill. I'll put it right there. I'm on the tail end of a cold and in my third trimester of pregnancy, so this is going to be great, but I'm excited to share with you guys the work that has been funded and ongoing from NIMH with my K01. I'm an early career investigator. I started my faculty position during the pandemic. Great time to start this career, but my work is going to be talking about, you know, from crisis to connectivity, thinking about innovative solutions to think about social determinants of health drivers, particularly related to black male suicide, which is the core focus of my research agenda at this time. So just a quick outline of what I'll be talking about, just the motivations to my work and the state of the literature, what we know, what we don't know, which is a lot, and then the current investigations from my research team, which I've nicknamed Grace, and then the future work because I am so new to this field and hoping to grow, where we're at now, where we hope to go, and what the ongoing studies will provide for this information. So just to start, and my personal motivations for thinking about this, this is a visual of the transatlantic slave trade, which happened quite some time ago, but you can see the various routes that enslaved people took from Africa to different parts of Europe, to South America, to North America, and what was lost out here outside of the physical embodiment of where these people live was also their culture, traditions, religious aspects, and psychological safety. My work really bridges the past to the contemporary, so this is really important to keep in mind, and this is kind of what undergirds my work and the framework, is that we do understand the contemporary issues for black Americans and people in the African diaspora now, but these are not new situations and new conditions. This was as a result of the displacement, as a result of the transatlantic slave trade, so I always have that visual to remind me and to remind my audience the massive scale of this event. To the contemporary now, thinking about suicide trends for black youth, and what we've been seeing in recent decades, although there has been this perception of cultural protection among African Americans related to suicide rates to their white counterparts or other racial and ethnic counterparts, there has been an upward trend that many scholars outside of myself have been tracking, so this is data from the CDC that Ariel Sheftal put out in 2022, but just looking at the upward trends of suicide death and those rates from as early as age 5 to 11, which is incredibly alarming, and I know there's some work coming up down the pipeline related to pre-teen suicide, which would be incredibly impactful for understanding where this trend is coming from, but also from ages 12 to 14, so we've been seeing this steady uptick, although we've been seeing relative declines or stagnation in other racial and ethnic groups. Thinking about the perspective that I take, I focus mostly on boys and men, and so here is the suicide trends by sex for ages 5 to 17 from this period of 2003 to 2017, but as you can see consistently, and this happens across racial and ethnic groups and in a general population, that males die by suicide at higher rates than females. We are seeing this really alarming uptick for black girls, which I'll talk about in my ongoing studies in future directions, but you can see in the blue line this upward trend for black males over time and over decades, so this is becoming an increasingly more pertinent public mental health crisis, and it's not going anywhere anytime soon. To bring in the structural determinant aspects of it, these things don't happen in a silo, they're determined by elements related to structural realities and drivers that frame mental health outcomes. I love this visual, it comes from New York Times, I did not create this, so I don't think I have this kind of visual skill set, but this shows different groups, white boys in the yellow and black boys in the blue, basically looking at the economic opportunities over the life course, so even though these individuals started in the same socioeconomic status of growing up rich, quote-unquote socioeconomic status, they don't stay the same way as they grow into adulthood. As they progress over time, white boys, as they transition to manhood, stay in the rich or upper middle class socioeconomic status, whereas black boys, as they transition to adulthood, have a varying range of socioeconomic outcomes and financial outcomes, educational outcomes that are important and really frame how we're thinking about mental health in this population, so you can't really do this without thinking about it in a vacuum. Another major social determinant of black male suicide that has come up is employment and economic opportunity. As I've mentioned before, this is data that I just got, but from the U.S. Bureau of Labor Statistics, as of January, black men experienced like a 5.3% unemployment rate compared to 3.3% among white men, so they've been having these high dips, very low ebbs and flows of unemployment, which has been really troubling and alarming, but has been the highest compared to other racial and ethnic groups. This is something really important to consider when you think about what is unexplored, so you have these structural determinants that are really undergirding how people are thinking about their position in the world and their status in the world, such as employment, education, etc. What I do and a lot of the work that I focus on is also the psychosocial, the interpersonal, but again, I want to mention, since this is a social determinant panel, that this is undergirded by a lot of the things that we're seeing that I just showed you in previous slides, but a lot of my work focuses on these unexplored factors related to black suicide research and men's health research, suicide research as a whole, one being masculinity and restrictive emotionality, which I'll define, because it's very jargon-y, and then everyday racism. So again, to Dr. Davis's point of discrimination as a social determinant of health, you know, racism is a multi-level social construct that happens not only internally and interpersonally, but at a structural and societal level, and I study what happens on an everyday basis. To give some additional terminology, masculinity is related to the shared cultural experiences of traditional masculinity. Think about the general scripts of boys don't cry and take it like a man. All of these things have an influence on how emotion is enacted and how it's picked up in the clinical environment. You guys are, most of you are psychiatrists or clinical researchers, and so the masculinity and male norms have a driving force here. The limited disclosure of someone's problems and emotional behavior problems to preserve their own masculinity and masculine role norms, that's restrictive emotionality, so they're kind of one and the same. And then everyday racism, which is semi-explanatory, but daily compounded instances of unfair experiences. So everyone here experiences discrimination on some level, gender discrimination, you know, like size or physical mobility discrimination, but everyday racism is specifically these daily compounded instances of unfair experiences due to your race. And again, it doesn't have to be actual, even perceived racism has a physiological effect on people's bodies and their outcomes, and so I bring that into my research. The emerging questions that I have that will take probably my whole career to think about, and the emerging questions that I'm going to talk about just briefly today are just, you know, what can we do to enhance crisis interventions for black men, particularly those in that really critical transition to young adulthood, where economic attainment, education, all of those pieces are critically important, and then how does social determinants of health interact with these factors to exacerbate mental well-being and suicide outcomes. So this will take me a while to fully achieve, but it's been the major undergirding questions of my career as an early researcher. So transitioning to the studies, the study that I'll talk about, and this is again graciously funded by NIMH, but also American Foundation of Suicide Prevention. My research team is based at Johns Hopkins. It's called GRACE. It stands for Gender Racism and Afrocentric Early Intervention. The I is silent research team, but we look at mental health disparities in black communities locally in Baltimore, but also again, as I mentioned, across the country and across the world in the African diaspora. I'm really focused on community based work, also mixed methods work, so you will see some qualitative and quantitative here, and we really want to understand how racialized experiences influence outcomes related to suicide, but also other mental health outcomes. I also study depression, anxiety, and other related psychiatric conditions. So the study that I'll talk to you about today is entitled Examining Suicide in Real Time Among Young Adult Black Males. You see there's a smartphone there. I'll give you more details as to why there's a smartphone. I'll just preface with the study objective. So first, again, my study was really interested in understanding the role of everyday racial discrimination. As Courtney Cogburn and others that are racial scholars mentioned, there's death by a million paper cuts, different microaggressions, small slights that happen in your everyday life that you're like, whoa, what was that? But how does that have a role in real time in exacerbating suicide thoughts and behaviors, particularly among young adult men residing in Maryland, because that's where I'm based. And then really to think about, is this method feasible? The method that I'll talk about, ecological momentary assessment, is not new. It has been well studied and well researched and has been applied in suicide work, but this population, again, has a number of social determinants of health and structural considerations that could influence whether this is an effective method of assessing suicide in real time. So I wanted to kind of do twofold things. One, how does everyday racism play a role? And then two, is this approach even feasible for detecting crisis in real time? Thinking about frameworks, so a lot of the pieces of my work and how I was trained, I'm not a clinician, I'm a behavioral health researcher in health behavior, is understanding frameworks. And so one of the most well studied and most well applied suicide frameworks is the interpersonal theory of suicide, which essentially proposes that two simultaneous psychosocial constructs, thwarted belongingness, so alienation, feeling like you're alone, but interpersonal alienation between one person to another, and perceived burdensomeness, such as I am a burden to myself and my family, those work in concert to instigate hopelessness, you know, thinking that their situation will never change, and cascades all the way down to suicide desire and a lethal or near lethal suicide attempt. This has been proposed as a causal pathway, but also just an interpersonal behavioral, you know, health behavior mechanism of understanding suicide. What I've been doing in the work that's under review is thinking about how to incorporate structural determinants of health into this framework. These constructs do not exist in silos, and so I spent a lot of time revamping the framework, which is under review, thinking about how education, health care access, economic stability, neighborhoods, etc., play a role in catalyzing this framework through the mechanism of power, which is in the tiniest font possible, but through the mechanism of powerlessness, feeling powerless about that situation, instigating other psychosocial aspects and physiological such as hypervigilance in one's environment, impulsivity, heightened impulsivity, control, and mistrust and avoidance, all the way cascading to what we see in this framework of a lethal or near lethal suicide attempt. So this is still being tested, because I'm still early career, but I've been trying to think about how we can think about structural determinants, social determinants, and how these play a role, because again, these constructs do not exist in a silo. So the mechanism for the study that I hope to use, that I've been using as smartphones, this is something that most Americans have in the United States, and especially most young people. So this is data from the Pew Research Center, about 96% of young folks 18 to 29 own a smartphone, and black Americans, 83%. So this is a widely accessible mechanism for reaching people, particularly for thinking about my population, where mistrust and avoidance of health care systems are rampant and deservedly so because of what we know about medical racism and psychiatric experiences for this population. A lot of times we're not catching people in those psychiatry units and these ER units, or we're catching them, but not for a long length of time. So I wanted to think about a mechanism that most people have, but will be used to assess in real time. Smartphones with that approach. So the method that I use is ecological momentary assessment. Some of you may be familiar, but essentially other ways to think about this is experience sampling, or daily diaries, they've been used somewhat interchangeably in the literature, although they're a little bit different. But ecological momentary assessment allows you to ping people in real time as they're navigating their lives and see how their mood, if you're assessing mood, shifts dynamically over time. So this example here, you're getting several pings a day, a lot, 10 in this particular example for four, day four, and you can see how the mental state of that individual, how are you feeling right now, how is your mood, and then this is also a way to assess your suicidal thoughts and behaviors. Again, this method has been used before in suicide research, has been well studied, and has really great success in a number of psychiatric populations, but hasn't been explicitly studied with black men and black Americans, so I wanted to understand this. The other wonderful thing about ecological momentary assessment and the beauty of smartphones is that you can track people's GPS, you can add other elements, looking at text data, you can add a lot more features to this so that you can see in real time how people's mood and environment influences their mood and shifts over time. So just briefly to talk about the inclusion and exclusion criteria of our study, we included black men 18 and up. Initially we were targeting these young adults 18 to 35, but we were also seeing interesting trends where folks over 50, over 60, over 70 were in the Hopkins psychiatric inpatient and outpatient units, which is where we're recruiting, so we tried to make it more inclusive. Again, the term of men is inclusive, this included cisgender and transgender men, and had a past history of or are currently in treatment for their self-injurious behaviors, ideations, and attempts, have access to a smartphone and English speaking. We did for this pilot data exclude folks with an active psychosis, there's a number of reasons why, and I can talk about that if you have questions, and cognitive deficits related to understanding the study in full, just so we can get that full informed consent. So those were our criteria for the study. We had two phases, again, as I mentioned, I'm a mixed method researcher. I really wanted to understand how racism as a social determinant of health influenced the experiences that the men had in our study. So we had a phase one of qualitative interviews, I like to say how much we paid them, because that's important too, where we talked about their suicide risk factors and what was happening prior to their suicide experience. Almost everyone in our study had an attempt, so we were asking them to kind of recall what was leading up to that. And our second phase was the EMA study, the full scale EMA study, where we gave them a phased incentive, if they completed all of their pings over time, they received $100. And so I'll give you kind of an overview of what the project procedures for EMA looked like, then give you some results and wrap up. So this is kind of how it went, we had our person in everyday life, once they did their qualitative interview, we gave them a baseline survey, had them download our app, which we were using Metric Wire, lovely Canadian company, there's many EMA companies now, and we tracked them for seven days. Again, this is a pilot study, there's been a number of EMA studies that have tracked for 45 days, 60 days, 90 days, but we wanted to get a sense of general feasibility and acceptability of this work. In addition to the EMA data, so they received four random prompts per day, and at the end of the day, we also assessed their everyday discrimination measures, there's a measure from David Williams at Harvard that's wonderful that we've been using, and also their sleep disturbances. And in addition, we also had passive data, which we're looking through now, I don't have that for you today, but GPS data and accelerometer data that we've baked into the study, just so we can see where they are, what's happening in their ecological and neighborhood context when they're experiencing these shifts in mood. So we followed them over seven days, and then we asked them how did they like it, because that was, we always wanna improve. So, here's some example prompts. So, with ideation, we used a Columbia Suicide Severity Rating Scale, which is, again, well-tested, and since the last assessment, have you had thoughts of killing yourself, yes or no? The intensity of these feelings, which gave us some really interesting and rich data, but also we had them do an event-driven entry related to racial stressors that were happening in their everyday life. If something was happening, we just had them record and just kind of speak into it like a journal. They used this feature very liberally, and we were able to get a lot of really interesting information, additional text and qualitative information from this aspect of our study. So, just to kind of briefly go through the descriptives, again, very small, so I'll walk through them. On average, we had about, the average age was about 32 years old. The sexual orientation was heterosexual for about half of our group, but we also had bisexual, gay, pansexual, and questioning individuals, and one who chose not to disclose. And again, the majority, about 67% of our sample was single, whereas others were married, separated, or divorced. Half and half employed, unemployed, and of those employed, half and half were full-time and part-time. And then we had most of our population with a high school diploma or equivalent. So again, you can start to see some of these social determinants play out here with employment, with education, et cetera. Given that it was a relatively young sample, not a lot of them were married, but you can kind of see how that plays through. So I'll orient you to a few key quantitative pieces that we have. This is a heat map, but essentially, we had yes, no questions, so it'll be shown categorically. TB is our thwarted belongingness measure, again, related to that interpersonal theory of suicide. And the question is, I feel like I belong. On the, let's see, left-hand side, so this y-axis, each horizontal row is a participant. So these are our first 10 participants that we had enrolled in our study, phase one. And then across is how many they completed of their EMA prompts. They had a total of 28 that they can complete over the seven-day period, four pings a day over seven days. But they were, to varying degrees, there were some differences in compliance. But you can see here where a lot of these middle folks, particularly participants four through six, were saying, yes, I feel like I belong. But you can see a strong kind of shift of the participant at the top all knows the participants at the bottom, number two and number three, those two rows there, saying no most of the time. You can also see how that relates to their compliance and how often they were responding to surveys. But in general, we had a mix of people feeling like they belong. And the qualitative that I'll talk to you about kind of gives you some, sheds some light on that. PB is perceived burdensomeness. Again, I feel like a burden to my family and friends. And in this case, I feel like people would be happier without me. Again, same orientation. Horizontal rows are participants in our study. So again, look at participants two and three near the bottom here. They're majority yeses, whereas for others, they're sprinkled in mostly nos with some yeses here and there, depending on their ping. And then someone at the top, participant seven, that has a number of yeses. If they didn't answer, then it's not applicable, that gray. But you can see kind of variation between how people are thinking about their belongingness in real time and their perceived burdensomeness over time and how dynamic and not dynamic that is in terms of it shifting. Here, this question, again, perceived burdensomeness. I feel that right now, it would be better off if I was gone. Again, you can see majority nos, but you have this high spike in yeses with participants two and three in some areas and some aspects of their time, completing the study over seven days. And then bring in suicidal ideation. So for those who said yes, we asked them how intense was that feeling right now. This was more of a continuous scale, so from zero to 10, although we didn't have folks do more than a six. But you can see, again, variation. A lot of zeros, a lot of ones and low numbers, but you can see areas and elements where there were spikes of intensity of suicidal ideation over time. We're still continuing to work with this data. We're still recruiting. So we'll have a lot more work to do, like real modeling, because this is a very small sample size right now. But it gives you a sense of how people's psychosocial feelings of belongingness and burdensomeness relates to their ideation and intensity in real time. Qualitatively, we had a lot of rich information that explained what we found quantitatively. So I'll just talk about three, well, two main themes, but I'll show all three here. Again, my work kind of looks at the synergy and the interplay of racism and masculinity. And what we found qualitatively, again, prior to before they did their EMA study, was that multi-level experiences, so not just interpersonally, but societally, collectively, community-based levels of thwarted belongingness and alienation was really, had a racialized aspect to it. So they were feeling like they didn't belong due to their position as a black man in the world and their racialized alienation in society as a whole. Then to the right, traditional masculine norms, again, like take it like a man, boys don't cry, all those elements of kind of holding it down, those did play in part with their aspects of being black and being strong, right? Because that is a strong cultural concept in black research and the black community. And so those masculine norms impacted help-seeking prior to their crisis situation. And in hopelessness, so again, we did see the same pattern of belongingness and perceived bonelessness leading to hopelessness, but there were more structural circumstances that catalyzed their suicide decision. There's no point in moving forward, I can't change my status as a black man in society, et cetera that elicited elements of hopelessness and moved them towards thinking about an attempt. I'll talk in more detail and give you some examples from the qualitative themes of the first two. So again, the first theme of thwarted belongingness due to structural determinants of health, this was presented prominently in the lives of black men at multiple levels. We have this study under review right now and under revision and I should finish that revision sometime soon, but this is the biggest kind of piece. There was interpersonal, what we typically see in this theory where they're feeling alone in their peer groups and their family groups or one-on-one interactions, but what was interesting and distinct that is moving this theory forward was the societal alienation. So this individual says, you know, as far as like experiences with racism, I've experienced racism, whether it be subtly or overtly throughout life and especially in instances where you're depressed or you're questioning whether your life should go on, those things can also start to play in your head where it's like you're not seen as a valued member of society. You're starting to see this linkage related to their experiences of everyday racism, that cumulative impact of that burden related to when they're starting to question, being here in this world or dying by suicide. The second theme, prevailing traditional masculine norms, was really interesting and of course, for those who do men's health research and if you're a suicide researcher, you inherently sometimes do men's health research because of the statistics, but it was really interesting to see how they talked about the interplay of this as a black man. Living as a black man is very different to living as a white man, as this participant said, and having expectations within your community and outside of it, being strong and unwavering in the face of literally everything when it's impossible for someone to do that without struggling a bit. So they're starting to show how that wall is starting to come up, that was the picture I tried to find of that wall is starting to come up of not showing that you're struggling but still maintaining that sense of strength and unwavering aspects in spite of all the social determinants and structural factors that are happening in their everyday life. So two examples from these two things, again, this study is under review, so hopefully it'll be out soon for you guys to see in full, but it's been really interesting to match this with the quantitative data, thinking about the belongingness and the perceived burdensomeness, how we can improve these measures, et cetera, keeping social determinants in mind. Something that we found from our racial stressor records, again, with this feature of our EMA study, they could press a button in their everyday life and talk about what was happening, we were able to get some rich information there. We were able to see some physiological and also structural concerns. So this individual said, I'm about to leave my house, and they were having a really hard time leaving their house that day and the whole seven days because we were starting to look at their GPS data. I always get really anxious about just leaving the house and having to get in my car and go anywhere. There's a lot more text here, which I didn't want you to read the full transcript, but essentially this was around the time of the lockdown, George Floyd, a lot of racial and civil unrest related to Black Lives Matter and the unjust killing of unarmed black men. And so this person was just completely nervous to leave the house in general. Again, I conducted a study in Maryland, in Baltimore, Maryland. We also had Freddie Gray going on during this time and other instances of racial injustice related to state-sanctioned violence. And so this person was having extreme anxiety, which in turn influenced their mental well-being, but it was related to that social determinants of neighborhoods where you live, work and play, that built environment and what was happening related to racism as a social determinants health as well. This person is saying they've been doing research into the history of African-Americans in America. And I mean, things have gotten better, but not even, I don't even know if I could say if they're getting better. I feel that way sometimes. It's just depressing, I guess. And it's more like it's getting different. I mean, crap sucks, I didn't take that one out, but like it's life and that's just how life is. So this person had really high hopelessness scores. I don't have that to show for you today, but this person in particular was having a very intense experience of hopelessness because they were like, this is just how life is. And we were able to grab that from this interesting way of conducting this research in their everyday environment that we wouldn't have been able to get in a one-time cross-sectional survey or even a longitudinal survey because these things happen and are dynamically shifting over time. So those are just a taste of some of our work. Obviously, we have a lot more work to do. Some concluding thoughts that black men in particular and boys as they transition into manhood have intersexual and cumulative experience that are driven by these social determinants. Again, these don't exist in a vacuum. And that informs their suicidal thoughts and behavior. So it's really important if we're thinking about public health, which I am, public health interventions and preventative aspects, where should we start to intervene? These social determinants and elements of where these people live their everyday lives are gonna be critical context for employing just-in-time adaptive interventions, ecological momentary interventions, and so on. Both social determinants of health, so they talked about housing and education, community and healthcare, and the societal pieces of traditional masculinity and everyday racism. Again, those unexplored factors and suicide research, both of those work in concert during critical moments leading to crisis. So it's really important to identify these levers of potential intervention, areas that we can improve or intervene with so that that can be used for enhancing mental well-being. I will also note, and I took this slide out because I didn't know how much time I would have, there are some protective factors. A number of these black men were fathers, for instance. I think about, since I'm expecting my baby, my husband, and it's gonna be a father, and how that was a really important protective factor of tethering them in these moments of crisis to this world, of saying, I don't wanna die by suicide, I have my daughter to take care of, I have my family to take care of. So some elements of traditional masculinity. Masculinity is not all bad. I know it's very weird for me to come up and talk about masculinity, but there are elements of it that is protective, such as providership, such as fatherhood, and other elements that could be leveraged in future studies. So I just wanted to put that out there because that's something I've been percolating on, personally and professionally. Some future directions. So I have a commentary out with Roland Thorpe. Just thinking about recommendations for this field as I grow in it as an early career researcher, but as others who have come before me are looking at, but prioritizing funding has been a really important thing. Very thankful again to NIMH for funding me, and AFSP for getting my early pilot work off the ground. A lot more of this work needs to be done. Innovative solutions, again, to maintain continuative care. I think smartphones is a really important element. Ecological momentary assessment is a very important thing that we could use once people are discharged to maintain continuative care and linkages and caring contacts, to maintain and tether black men, in particular, to healthcare sectors, but also the experience they have in the healthcare environment is critically important, so please be mindful of that as clinicians. Black men are not, black populations are not all one size fits all, so there's a lot of heterogeneity here, and it's really important to capture that variability of, again, from the transatlantic slave trade picture, there's a number of cultures and environments that are being brought over, there's a number of immigrant populations that are here now, and so we can't really think of this as a one size fit all solution. Crisis support hotlines are an important piece of advancement, but it's really important to not couple that with police involvement and intervention. That was something that was a critical part of my safety plan, and I'm happy to talk about in Q&A. And then again, community stakeholders should be at the forefront of this work. A lot of this was driven by community engaged researchers and people that we're with. I have a number of partners at Hopkins and at Roberta's House, which is a bereavement center, and with SAMHSA, and with other folks related to thinking about community coalitions and collaborations for suicide prevention, enhancing gatekeeper training for the community, because this is not one thing that can be done in the healthcare environment. Again, it needs to be moving outside of that environment and include community aspects as well. And then a couple ongoing studies. My youth companion study is the K01. So we've started this work, and we have a number of dyads now, which is fun, youth and their caregivers, and we've included both boys and girls because of that really sharp uptick with black girls in suicide that I showed you in the earlier slides. We really need to think about what is happening there, and I have some ideas, but we need to get into this a little bit more in depth. So we're continuing and modifying this protocol for EMA for youth, and we'll be expanding this to recruit in the coming months for folks admitted into Hopkins Pediatric Emergency Unit for, so Hopkins does an Ask Suicide questionnaire, which is universal for questions for everyone admitted in their pediatric ER, which is great, but also for those who come with a general mental health concern or complaint. And we also have provider studies, so if you're interested, please chat with me, of thinking about how we can integrate this better with patient care, with EPIC dashboards, et cetera, to make this a little bit more palatable. I understand there's a million things that you guys as psychiatrists are doing, so one more thing would be too much. But this is important for thinking about how we can make this more accessible in terms of dashboards for monitoring health risk outside of the healthcare environment. So with that, I'll conclude, a number of people and collaborators that helped inform this work, so I couldn't have done this without them, and particularly my participants. And this is the best way to reach me across all channels. Probably email's the best, because I live there, but this is the best way to see what's happening with our team and projects ongoing, and how to reach me on social media. So thank you guys so much for your time, I appreciate it. And now I'll introduce, I was going to say, are you introducing or I don't know if I can press it. There you go. And now Dr. Alegría. I want to thank NIMH for giving me the opportunity to present this, and I want to say this is work by also Gabriela Stain, who's now at Austin, University of Austin. Let me go, and I'm going to walk you through like five different things. But I also want to talk, you know, in general about three studies that we have done on social determinants, and try to put it all together. I have no conflicts to disclose. I wanted to start that actually people have expanded the definition of social determinants of health, and they've actually, I was glad that you presented, Dr. Davis presented the first definition, and now they've expanded it to not only say conditions in which people are born, grow, work, live, and age, but actually it's people access to power, money, and resources. And I think those are really important additions that they've done into the definition. I also wanted to talk about, you know, how people have really changed what's included in the definition. And Dr. Davis made some relationship to this. But now stigma is something that has been included. Lack of mental health parity, for example, which was never part of the social determinants. People now talk a lot more about social connections, about loneliness, about the effects of social media. Immigration, for example, has become a lot more prevalent in how we think about social determinants. So now we really have a lot more things to bring on. This is the one that's currently being used by the New York State Office of Mental Health, and I want to bring this on just because they really talk about the adverse built environment, for example. They talked about neighborhood disorder. So depending what model you use in your social determinants, depending what you're going to find. And I want to emphasize that because the data I'm going to show you, we use the social determinants that Massachusetts had really put into Medicaid populations. And it was very limited. And so you see that now there's a lot more, but then you have to select how are we going to prioritize when you're thinking about all of those social determinants and you're a policymaker, which is something that one of the policymakers asked me. Well, I mean, Maggie, look at this. You have all of the social determinants, you know, low educational attainment, unemployment, housing instability, food insecurity. How are we going to address all of them? And so this is something to think about. I'm going to walk you through intervening in the social determinants and especially the social determinants within mental health. I did two papers, and this is how I started with social determinants. This paper of 2018 really has been cited a lot. I was really surprised how many people cited this paper of social determinants of mental health, where we are and where we need to go. And then I did a second follow-up paper, which was on recent advances of social determinants of mental health, looking fast forward. And you don't have to read the papers. I'm going to give you a really short, brief overview of what are the main things about the papers. First of all, I mean, one of the main things that I cover in those two papers is how the frameworks have really expanded from the individual to much more contextual factors. And that is a challenge, I think, from the perspective of really trying to come up with How do we address issues that are in the context that require a different type, completely a different type of design? And then a lot more on protective factors, because so much was focused on the negatives and so little on trying to identify the protective factors, such as psychosocial and community strengths. And this is something, for example, that our youth talk about, how much we're focusing on the negative and how little are we focusing on the positive of their context. And this is particularly for low-income neighborhoods, where they feel we stigmatize the neighborhood by talking about disadvantage, low education, low resource, and very little about other things. The other thing is, I mean, I think COVID-19 made it very clear about the importance of social determinants. But I want to emphasize one thing we are not looking at. It is the social processes of minoritization that are part of the causal pathway. I think, you know, Leslie did a great job of talking how it's not only thinking about what people are not getting in terms of resources, but actually the processes that really relate to how they feel about not getting those social determinants. That's an area we have done very little about. The other thing is that we need to not only think about the social determinants at the individual level and the community level, but also the policy level, because that's where our biggest impact would be. And then the last thing I'll say, in reviewing all of this literature more recently and even before, there's not that great rigorous studies, I have to say, of the impact of the social determinants on mental health. And this is where I'm going to talk to you about the studies that we have done. One thing that came up, and people don't talk too much about it, but I think it's a really interesting debate, is this issue of are we giving to the healthcare system to do the social determinants when they really are stretched out? Is this a good idea of, one, giving it to the healthcare system where, one, it's very, very costly and labor-intensive in hospitals to attend to this social determinants, to, you know, in hospitals with more funding and more resources, social workers, although they have the expertise, many times they don't have the power to change what is needed and get the resources. And then health systems and organizations have mismatched goals of trying to attend, you know, the health things of people versus really attending their social demands or needs. And I'm going to talk about this because her idea, and this is Sherry Glead, who's a real dean of Columbia, and was saying how she doesn't think this is a good idea of combining both. And I'm going to show you some data at the end of whether we should or should not combine both. I also wanted to raise one issue that is never thought about in social determinants, and that has to do with, you know, it is true that some of the social determinants, for example, Housing First interventions, they're actually very good in terms of doing stable housing, showing that it really helps increase, for example, engagement in office visits for mental health. But there's also some evidence that it's not very structured and not very well defined who receives it. And also that by giving housing, we're not also giving a lot of other social determinants that need to be coalesced under the same intervention. For example, people have talked about unintended consequences, me being one of them. For example, we know that moving to opportunities, for example, had negative consequences on black youth. So we need to think not only about what happens with the social determinants, but are there negative consequences that we're not seeing? I want to show you another example. This is policy-level programs of urban planning. For example, people are saying that putting all of these green spaces, which have shown to be very effective with depression and anxiety in youth, but have also caused displacement because the more we build those green areas, the more people that are well off want to buy on those neighborhoods and then displace some of the people that are already living there. So there's a lot of issues of marginalizing the population when you improve the community, and not that we don't need to do those green spaces, but we need to also be aware of how we can make sure that we don't displace the communities that live there. So I'm going to talk first about the first one of the studies that we looked about the need to go beyond social determinants of health screening and referral. This is a study we published in American Journal of Public Health, and what we found here is that we were looking at whether people, just referring people for social determinants and connecting them to referrals, how much did it do in terms of PTSD, and how much it did in terms of functioning and quality of care. This is starting to try to see what is the impact of giving social determinant referrals, screening and referral, which, by the way, it's paid, for example, in Massachusetts, we pay for that, and in many states, we pay for screening and referral. So there's a lot of incentives to do screening and referral. And this is a big study that we did in North Carolina and Massachusetts. We screen around 2,600 people, and of those participants in Massachusetts and Carolina that had actually either moderate to severe depression or anxiety, and we invited them if they were actually high in depression or anxiety, we invited them to be part of this study that we were doing, offering a psychosocial intervention. And you can see here we got 1,144 people eligible, so a very high rate of people were eligible with moderate or severe mental health symptoms. We randomized them into an intervention, and the intervention was for the people that went to the intervention, they got 10 sessions of what we call strong minds, and this is an intervention I'll talk more about with a community health worker over the course of six months, and they also got social determinants by a care manager that actually screened them and referred them to services. The people in usual care, we only gave them the screening and referral to social services, but they didn't take the intervention, and I'm going to show you two aspects of this. What we're going to be talking for the first part is going to be on only the people that were in the enhanced control condition, only people receiving the social determinants because we could follow them over the course 3, 6, and 12 months. And you can see here, this is the social determinants of health that's used in Massachusetts. We pay to Medicaid populations for doing this assessment of social determinants and for referring people to services. And what we wanted to see is what was the impact on the Hopkins symptom checklist? What was the impact on the World Health Organization disability assessment schedule in terms of functioning? And what was the effect in the also post-traumatic stress disorder, the PCL-5? And finally, on perceptions of care, the global evaluation of care. And you can see there, we had transportation, utilities, housing instability, trouble paying for medications, child care or family care insecurity, unemployment, and food insecurity. Only this is a mixed, multi-level mixed effect model, which was fitted to repeated assessments at 3, 6, and 12 months, and we, people were recruited from September 2019 to January 2023. So very recent data. And we looked at only the cases for this piece of the paper, only the cases that were unusual care, receiving the care manager, and referrals, screening and referrals to actually social determinants. Let me give you the answer to the five questions we asked. The first thing we saw is food insecurity was the most common social determinant, both in North Carolina and Massachusetts. You can see there around 62% of people in Massachusetts asked for food insecurity, 52% in North Carolina. Housing instability was also high, around 30 to 40%. Utilities also high, between 30 to 40%. And unemployment the same. One thing that's really striking was how much more people in Massachusetts asked for more social determinants than people in North Carolina, and we think it has to do with the marketing. People in Massachusetts had a lot of places that came in the news, came in the radio, came in the TV about having help for people, less places in North Carolina. One of the things we saw is participants with higher psychological distress, PTSD symptoms, and lower functioning were the ones asking for more of the social determinants. We found that both black and Latino were more common asking for social determinants, much less the Asian population in these two sites. And it's interesting that this is adjusting for baseline characteristics of all of these groups, and still Asians were less likely to ask for this information. We also found that people with lower education were asking for more social determinants. And as expected, what really predicted who was getting more referrals were the people that were reporting more social determinants. So we didn't see any bias of the care managers in terms of giving more referrals to low education or younger age. There was no bias whatsoever. It was only for those that had more social determinants. In terms of the relationship of the social determinants referral to mental health and functioning outcomes, we found no effect of referrals at screening and referrals of social determinants with improved mental health outcomes, except higher reported quality of care. So, people that receive more referrals for mental health said that they were actually getting better quality of care, but none of the other referrals seemed to make an effect. However, we did find that the type of referral didn't matter. And I think this is important because we, many times we do the analysis on the number of social determinants and not on the type. And we did find that a participant who was more likely to be referred for services because of trouble paying for utilities had lower self-reported PTSD symptoms at follow-up. And the same, we find that people that were referred because of unemployment had lower self-reported PTSD symptoms and higher self-reported levels of functioning at follow-up. So the type of referral does matter. But if you look at referrals overall, you might miss the effect. Now let's go in, this is the other next part we wanted to see. We wanted to go back to the full sample and look that social determinants impact the effectiveness of an evidence-based intervention. So now we have the impact of the evidence intervention. And do people that have more social determinants do better or do they attenuate the effect of the intervention because they have all of the social determinants? So how can we use this information to help us understand is it better or does it attenuate or diminish the effect of the intervention? We actually did the same group. Now we have the people that were in the intervention and compare it to the people that were not in the intervention. But now we're looking at having more social determinants and having actually the intervention with people that have social determinants of health. I want to show you what the intervention is like. This is a 10-session psychosocial intervention. It was given in four languages, Spanish, English, Mandarin, and Cantonese. We're now also doing it in Arabic and Haitian Creole. And we do show we actually and this was an NIMH funded grant huge two grants that were funded together and we did find that this intervention actually is quite effective for depression and anxiety. I'm not gonna talk too much about it but because this is for social determinants but just to show you that the intervention has a big component of mindfulness a big component of psychoeducation and CVT skills that are combined in each of the 10 sessions and they're provided by a community health worker that is a supervised by a licensed clinician on a weekly basis. I want to also talk about you know process I told you about the importance of process and I think in many of this research studies we don't talk about what we are teaching the community health workers to do to change that process with the interaction. One of the things is that the in this study the CHW actually introduces themselves it's not like a like I don't want to tell you about myself but actually introduces themselves and ask the participant to introduce themselves. There's a lot of focus on what the client talks about their problem and living circumstances so the CHW actually learns a lot about the living circumstances of the participant. There's racial and language concordance so we try to make sure that there's racial and ethnic concordance so there's a shared narrative and I can talk into this because it makes it very challenging to have racial and linguistic concordance and then the intervention is treated more as a coaching that as a treatment. We don't talk this is not like treatment this is more like a coaching intervention and then the social determinants are really central in trying to get people what they need to deal with adversity. We actually found that at six months participants with lack of transportation had a larger improvement in functioning relative to the average intervention effect for all participants. We also found that at six months the participants with problems paying for utilities had a larger improvement than the average participant. We found the same thing at six and twelve months for people trouble having trouble paying for medications with a larger impact. The same thing for housing instability in other words we found that actually for the people that had the more the social determinants the intervention had an even bigger effect so even adjusting for all characteristics at baseline so it shows you that actually this is the group that really benefit by the combined psychosocial and social determinants combination and then finally the one that we didn't find any effect is if you had participants that had child care or family care responsibilities those people did not benefit more than the average person so nothing that we were doing was really helping them. So my main topics for you this is my end talk is I think most models and theoretical frameworks that identify social determinants of social determinants of mental health they just identify what it is but not how it works. I think we're missing the how it works and and this is a real big problem because I don't think everything works the same as you can see here and it also will not work the same for people depending on what they are needing. I think also that when how we intervene with the process of social determinants could have unintended consequences and further stigmatize so the assessment process including how you do the incentives for people to be willing to engage and not feel like we're devaluing them because of the social determinants and having a positive experience with a person that the person that's receiving it is really important and then it really shows that if you think about it you need to combine both you need to combine the aspect of the psychosocial education intervention with the social determinants but social determinants by itself without no intervention no help might not be sufficient to do the effect. Thank you so much. So with that that concludes our presentation but we want to open up for panel discussion and Q&A and so before we do that I have some some good questions for Drs. Adams and Alegría and while you're thinking about your questions one thing to keep in mind this I don't know if the sign is still visible they said to make sure you use the microphone in the center of the room. So the one thing I'm going to start with you Dr. Adams since you presented first and I wanted to think a little bit more about your work on black youth suicide. You talked a lot about like sort of discrimination and everyday experience of discrimination as a social determinant of like suicide outcomes for black men and so I'm wondering you know there's some other literature suggesting that like black families tend not to engage in services until like a catalytic event and in this case a suicide attempt could be considered a catalytic event. So how do we act on you know discrimination or these ideas of masculinity to get you know black men in particular engaged in care sooner? Okay can y'all hear? I don't want to like rip this out. Okay I love that question and that's I have a health care focus of getting them in but to focus on the community aspects as well. A lot of the challenges recognition of the challenge ahead of time before you get to this crisis element but also now that we're moving into this to youth environment like family recognition family acceptance and what some of the barriers are there. So we're starting to tease that out. A number of the caregivers that we've already started to talk to as part of my case study you know talked about you know this is not how African you know this is not how black people like this is not what we do. We pray it away and so you know typically like religiosity or religious involvement has been seen as protective but in some cases it can be seen as a deterrent to seeking health care aspects. So we've been working on enhancing existing gatekeeper interventions that are community focused for black populations. That's one of the works that we're doing now in Maryland and in Virginia because I feel like community voice and community urging is very impactful for getting them into the health care system but also positive experiences in the health care system are needed. A lot of time black boys and men are entering involuntarily through police involvement or court order involvement and so if you're entering a system of therapy and care that way you're not going to want to continue that way. So thinking about more voluntary aspects of seeking care but in order to do that there needs to be that initial recognition and support and urging which we haven't quite gotten collectively yet. So with identification with understanding like it's okay to have these feelings a lot of people have passive ideation so just kind of normalizing what's happening especially for youth that are developing their identity in real time especially for LGBTQ youth. So a lot of it is like caregiver intervention but also community involvement because it's not just the family is more of a collective unit in this in this population so it's community uncles, community aunts, grandparents. It's not just the mom and dad in this scenario where there's really tight-knit neighborhood cohesiveness at least to urge and support people to seek care long-winded but that's it. Thank you so much. You spoke about community involvement there so I'm gonna open this question up to both of you but like how do we better partner with communities to address these social determinants of mental health? I mean there's been lots of work now being done on community-based organizations which have been amazing. I mean this study was possible. We were able to participate and get so many of those people involved because we partnered for with them from the very early start and not only did we partner with them from the very early start some of this community-based organizations have known us for 10 years so they felt very comfortable in partnering with us. I think we also need that but I also think one of the areas where we are lacking is getting policymakers involved. Like recently I'm doing some work actually very much in line with a crisis for use in Indiana and we decided to do one meeting for the community, one meeting for policymakers, and one meeting for the mental health providers and the reason we wanted to do those three meetings is because first the audience is very different and what they're asking for seems to be very different and also because I think you need also policymakers because a lot of the community-based interventions require long-term sustainability which a grant of five years is not going to give you. So by the time you get trust with a community you actually build your partnerships you know your MOU you start doing it it's gonna take a long time so I think you need that and then I would say asking co-designing what the community wants with you. When we did in Massachusetts some similar work the youth did not want a clinical intervention they told us please don't do another mental health intervention for us we're pretty tired about mental health interventions so it really required to change completely to what they wanted and actually it looks like that intervention which we're testing now might work better. And I'll echo I mean the it takes a long time to build these community partnerships you know I identify as African-American I'm in a predominantly African-American city in Baltimore and but I work at Hopkins we know like the history of that institution in that environment and that's been challenging to like I just be honest to set up those those interactions and those community linkages as an early career person the strategies that's been helpful for me is to emote like to create the memorandum of understanding early co-create together and have them be like major drivers co-PIs on a number of projects because they know the environment and the city way more than I do you know I'm considered a transplant which makes sense and so they they have seen these issues time and time again come up and they seen academics swoop in and swoop out and so you really have to make that sustained commitment and pay them and honor their time and and move things to their you know to their turf and and really work in a collaborative space and that's that's not necessarily like you said I'll agree in the structure of a five-year NIH grant or in the structure of an academic lifestyle so you have to be really intentional and I'm still working on that as an early career person so yeah thank you both so much I'd like to open it up to the floor if there are questions or comments that folks have so you talked about the difficulty of people participating and accepting referrals but you were both doing research studies and what about the people refusing to participate at all so how how many views and how good was your samples in the end thank you for asking that question so I can tell you the refusal rate was around 30 some percent high 30% and a lot of people say you know one they said you know many things some people said they didn't like research some people said they were this is I don't have the time I have too many too many responsibilities so I think it was different reasons but I think overall we found that that rate was a lot higher than it's typical in studies of this type and I think it was also because the person that actually invited them to participate was typically race and language concordant well do you think it makes a difference to the results yes absolutely and that's one of the problems of research data I mean I don't want to dismiss that research data is tends to be biased but this is really a diverse one of the things that NIMH was super thrilled about was that this was a very diverse you know a sample if you think about it it's very very diverse and I think one of the things that made it diverse and I should tell the audience this is we didn't not ask for Social Security numbers so one of the things that made it very different is we we told NIMH if we really want to have a diverse you know sample of people we need to take away some of the things that really refrain people from participating yeah we also track dropout rates within the study so of people who said yes they'll do the study we had to track them over time and as you can see like as you continue across the study like compliance changes right so we were really interested in that and the why thankfully everyone even if they didn't complete their EMA surveys still did an exit survey for us so we were able to ask like what are some of the reasons that you did not participate even though you're a participant in the study very interesting findings one is that especially if you think about repeated assessments of suicide how that affects people's mood for instance there's been a lot of studies saying oh we can do repeated assessments of suicide it has no effect on instigating suicidal thoughts and behaviors true but if they're already coming in with depressed mood these are people that were discharged for a suicide attempt they already are in vulnerable and high-risk for these individuals if they're already in a depressed mood and they're getting frequent assessments of oh how suicidal are you how about now how about now they're not going to want to complete the study so we were able to get that very helpful feedback for us in our future iterations and for the youth study we're actually thinking of shifting it from our Columbia suicide questions to like reasons for living a more positive framing of like what are some things that are tethering you here today what about now what about now and think about moving more protective measures in there because even within the study itself it's a very challenging grueling study and especially if you've had a suicidal experience it makes it even worse so we were able to track some of those reasons which is has been helpful because typically when you see non-compliance and and papers you're like okay those are just people that but there's more to it you have to dig into the why so we're able to do a little bit of that so you're talking about the people that didn't complete the study but how many refused to enter from the beginning that's tricky I mean we reached out through like my chart so it's a very broad swath I would say we were able to recruit of that I don't know I have to look at the numbers again I might get best guess is close to 10% of the people that received the my chart message did the interest survey so it's a very low but we reached out to like a broad group and said if you're interested do the survey we've been thinking about other methods of doing community events etc etc through AFSP and other you know advocacy groups so that's ongoing but the way we recruit it was not necessarily like an approach in the in the ED we didn't do it that way we did it through their my chart messaging for the youth study we are doing approaches in the ED right now we have 10 dyadic parents and kids signed up out of I think we have 50 people to reach out to like we're still in the early stages of recruitment so I'm really excited to see that data I have a feeling it'll be mixed as well yeah thank you thank you both my name is Jay I'm I have one foot in psychiatry one in high performance building and we like to talk about often how when you have triple pane windows and really well built building it's very quiet and that can reduce stress levels for tenants and occupants and I'm wondering if you've seen any correlation in your research between improve stress suicidality depression other things when you have increased noise pollution no I haven't I mean there there is some I actually did one paper environmental sciences and they had some some some of those types of conditions I think there was a study on noise pollution I think it was on Denmark who has some of the best longitudinal study and actually they they do registry so everyone's included and they and then they have information around the site the one I I mean people are now doing some studies on heat and heat being one aspect affecting but I think there are people in environmental sciences that are doing environmental sciences and mental health so I I really highly recommend it yeah hasn't come up in my studies yet again mine are like really pilot demonstration studies but we were in city centers and urban environments so you can imagine what the noise pollution would be in those settings so I it's something we should look into we have our GPS data that we're still looking through and maybe we can map that on to some existing noise pollution data that exists yeah no you're fine oh it's a check with the FFA yeah Great. Oh, great. Good. I really think we did a study with a big sample in the South Bronx, and they talk a lot about light pollution, about not being able to sleep because of the lamps that they have for vigilance. So that might be a really important area. I mean, this is in the qualitative piece of the study that we did. People talk about the lamps for vigilance as affecting them. That's interesting. Any other questions? Thanks for the presentation. I have lots of questions, and I'm trying to just figure out which one to ask. I'm Stephen O'Connor, and I chief the Suicide Prevention Research Program at NIMH, and really appreciate this panel and both these presentations. I was wondering, have you all looked at some of the mitigation strategies from the federal and state governments around COVID and how those might have impacted some of the health outcomes, suicide outcomes? There was just such a massive investment in addressing a lot of these types of issues. And then there's been a phase-out of those as well. And so just wondering if that's caught your attention and if you found opportunities to study that. Do you have some examples of what, I guess, because I'm less familiar? Well, yeah. So one of your colleagues at Harvard has shown that caste transfers in Brazil are associated with suicide risk reduction, right? And so essentially, through a lot of the stimulus programs that we have in the United States that help support people, that helps with economic stability. Because we were really worried that at the beginning of COVID, there was going to be a massive increase in the rate of suicide in the country. And it didn't happen at large, but it did happen for certain demographic groups including black individuals in Maryland and some other states. So I just think it's an unfortunate, but it is an opportunity to try and study. There are policy strategies essentially, right, that were enacted, and a lot of them are not sustainable because they're costly. And a lot of times, they weren't necessarily delivered with equity. And so there's just lots of opportunities, I think, to learn from that. Yeah. I will say it didn't come up specifically related to COVID-19. We had a number of participants that were recently unemployed, and that was part of the precipitous leading up to their suicide experience. One for a number of reasons, I mean, I studied racism and masculinity, so a lot of the providership aspects were lost, financial attainment that they tied to their identity. So that was kind of how it came up, but they didn't tie it specifically to loss of certain mitigation strategies. But it was clear, we conducted these interviews between 2021 and 2023. And a lot of our 2021 participants had positions that were newly created or that they had recently attained that were no longer available or that they had lost access to, you know, different aspects of their money stream for different reasons. But they didn't tie it to COVID-19. That'll be something we should, that'll be interesting to dig into, because I do feel like for black men, a lot of what came up qualitatively was the job. The job was really driving their mental well-being. And the number of them that were really high risk had recently lost their jobs for a number of reasons. Yeah. I have to say that we really didn't do a good job of planning. And I think people have said, we need to be ready for the next one and do, you know, difference in different designs that allow you to look at people before COVID or some other thing, and then do, you know, discontinuity studies to try to see when things get discontinued, all of those helps. Do we see a backlash, you know, in people getting worse or not? But from our end, we weren't planning on that. We have more data that we could look, but not necessarily at the level of what the state gave. And I have to say, there's only one place that I was collaborating. And when they found out that we were trying to get information on whether the government had done a good job or not, they stopped the study. So there's also the backlash of not wanting to look very bad, one way or the other. So I'm just saying, it's not as easy to collect that data. All right. I think we have time for one or two more questions, if anyone has one. If not, I have other questions for you all. I'm just opening up to the floor. Yeah, go ahead. Yeah. Do you guys have any research about how expanding scope of practice could be potentially helpful or not helpful when it comes to racism in the healthcare field, especially like with the nursing field and stuff? Scope of practice? Is that what you're saying? Having more practitioners, I know nursing has more diversity in it than the psychiatry field does. Would it be helpful? So there is evidence on racial concordance and linguistic concordance showing effects, more positive effects. So there is some data about that. About scope of practice, it's very debated. I can tell you right now, I'm with the legal team at MGH because they didn't want us to move the dissemination to other sites that want it, that want to do this intervention because of litigation of scope of practice. And I just presented at SAMHSA for another thing, and it's very debatable, this issue about scope of practice. Actually, for those of you who are interested in this area, there is going to be a National Institute of Mental Health. The unequal treatment revisited is going to be distributed in June, I think, 15th. And we talked there about scope of practice and the issues of scope of practice. Thank you. Yeah. The challenge with racism is such a noxious, it's like everywhere. So it's not like you'll be in an interaction with your client or your patient and be like, well, this thing happened to me and I know it was right. It's never quite articulated in that level of clarity, I wish it was. Yeah, we do know concordance helps and it works. Also just getting in and being able to afford it has been the major piece for my participants. The cost is a huge, huge barrier and access to wait times are quite lengthy. So those take precedence before getting in with a provider that may or may not look like them. I will say a big thing is minimization of racial trauma has been a major thing that our participants talked about while seeking care. They will say this thing happened, and they're like, oh, well, that happens to everyone. That kind of thing. And so minimization is a huge mechanism. We know what it is, but how? Like being minimized in that experience that is a very, you know, trauma with a capital T to them and trauma with a little t to a physician or a nurse practitioner, that discordance, it could be race concordant, but if you're not really honoring that experience, then you're not going to have a good therapeutic alliance. So it's not necessarily just who is there and what they look like, but how they're responding to what the patient is saying. And we've heard time and time again that people's racialized experience were minimized because they're like, oh, well, that's just your plight. We've heard wild things. So just don't do those things. Yeah. All right. Well, I just want to thank you all for attending. I want to thank Drs. Adams and Alegría. Thank you for staying. Yes. Thank you so much for staying. Have a great day. Thank you, guys.

mental health disparities

gender and racism

suicidal ideation

ecological momentary assessment

racial discrimination

masculinity norms

social determinants

culturally tailored interventions

systemic barriers

racial trauma

community engagement

therapeutic alliances