Welcome to our symposium. We're going to be talking about the impact of social determinants of health. I'm Tatiana Falcón. I am a child psychiatrist. I will be describing some of the issues that we see, how the social determinants of health impact youth. Then Dr. Ruby Castilla is going to talk about the impact of the social determinants of health in women's mental health. And Dr. Fernando S.P. Forsen is going to be talking about how the social determinants of health, we see the impact in inpatient psychiatry. Really nothing to disclose. Some of my research focus on improving the access to services, but it's fairly funded. So the main objective of my talk is to try to recognize how the social determinants of health impact early in life can impact the development of mental health issues later in life. When we talk about social determinants of health, we're talking about how not only what is happening now, but also the conditions that the people were in before they were born, like the pregnancy, all the individual level factors, like the support that the people have, like family, friends, like the health system factors, and some of the cultural factors, how the experiences because of the culture can impact people. And then, so when we're thinking about well-being, we have a lot of different needs. So we have our physiological needs, our safety needs, our support needs, our needs to grow in our self-esteem, and our self-actualization. So when we're talking about health, we, health equities are very important concept that everyone should have, like a fair opportunity to be as healthy as possible. But this can be impacted by many issues, like poverty, discrimination, the consequences of the long-term discrimination, the quality of the education that people can have, and like not being able to grow on a safe environment. So if we start even looking at the early impacts, like how someone who was impacted by racism during the pregnancy, how that impacts the kid, right? So we know that racism can impact the mother and the child. Like an example of this is how black infants have like double the mortality rate compared with white infants, and because sometimes they don't get access to care, to get good prenatal care, then the risk of prenatal mortality is definitely higher. We also know that the preterm delivery is higher, and we know that preterm delivery can really impact your development, right? Like we know it's one of our first questions in child psychiatry, trying to understand how was like that first year, because we know those patients who went to an EQ and who had a lot of issues in the first year might have also cognitive issues. And so we know that black and Latinx infants are more likely to be born in hospitals that have higher adjusted neonatal morbidity and mortality compared to white infants. So we know that all these steps through life can really impact the development socially, psychologically, and these disparities impact how the kid learn to see the world. So in this study looking at data from 2006 to 2012, they were looking at how much money was spent on mental health services, and they saw that Latino children and black children were less likely to get these services and those disparities on mental health. Sometimes it wasn't just about the money, but we know that these kids, like black and Latino children, sometimes where they were having like behavioral issues or conduct issues, they were more likely to end up in the justice system than in the mental health system. So these disparities in care have been seen through many years. So if we look, some of the, you know, poverty really impact mental health. So if you grow up in a very poor environment, that impacts the food you eat, the choices of school, your friends, your neighborhood. And so if we look in this, you can see the difference like of poverty, the lower line is white, then you have blue is Hispanic, green is Native American, and red is African American. And so when we look, this study was looking at the social needs of Latinx families, and we know that when the social needs are higher, then that leads to more emotional dysfunction. So in this study, they look at 432 Hispanic families, and in this study, 40% of the children in the sample had symptoms with emotional dysfunction. And 37% of these houses reported more than five household needs, like not enough food, not enough water, one of the parents not good access to a job, right? And we know, like from all the other developmental studies, how the biological impact of stress, like in this case, like measuring the cortisol levels in women, her, was associated with distress in the kid. This study was really interesting because not only they measured the cortisol in the mom, they were also looking at the cortisol level in the kids in kindergarten, and they saw that when the mom had higher levels of cortisol, it was also the same in the children. So this is also looking at the 27% of the children, the parents don't have a secure employment, and we know when there's financial issues, that increases the stress in the house. In this study, we're looking at poverty, 17% of the children were reported to be food insecure, and how this impacts someone's performance, right? So we know poverty was also related to how people perform cognitively. So in this study, we're looking at race and math, and so they saw that there was a difference between problems and race. And we think this is not because there's a cognitive difference, it's because the social determinants of health impact some of the choices that the children might have. And this is looking at children expelled from a school by race, and they saw that more than twice as many black children were expelled from a school compared to white children. And when you look at youth in the juvenile detention center, black youth were 4.6 times more likely to be in a detention center compared to white youth. And that also goes with behavioral problems, right? So when these kids were having behavioral problems, when they compare white and black, a lot of the white kids were getting treatment, right? They were able to get services, and some of the black kids, instead of getting services, were going through the juvenile detention center. So this was a really recent study looking at how the social determinants of health can impact self-harm in youth with psychiatric conditions. So they look, this was a study looking at the Ohio Medicaid claims data between April 2016 to December 2018. They have 240,000 youth with a primary psychiatric diagnosis, and they were looking at different social determinants of health, like abuse, kids who were in the child welfare system, children who had educational problems, financial problems, death in the family, conflicts, environmental problems, and other increase in psychosocial needs. So 21% of the kids who had psychiatric diagnosis had at least one adverse social determinants of health indicator. And from this, 3,262 youth have reported had at least one episode of self-harm. So that's 1.3. And they saw an increased risk of self-harm in the kids who had more social determinants of health. So when they look at the different categories, they found that abuse and neglect, and actually what was really interesting was even higher on emotional abuse than physical abuse, 30% had more likely to self-harm, family problems 3%, educational problems 2%, and they look at the data in over a thousand years, and they report like the highest of the determinants in this study was definitely abuse and neglect. So in this group, they were able to demonstrate that the social determinants of health was associated with like non-fatal self-harm among youth with psychiatric diagnosis, even when they control for the demographic and the severity of the psychiatric diagnosis. So if we think about the effect in COVID, right, like we have the data from the CDC study that show like 40% of people were reporting at least one adverse mental health conditions, and like the suicidal thinking increased during COVID time, and when they look at who had the different and increased rates of suicidal thoughts, it was younger adults, it went up to 25%, and minority kids like Hispanic kids and African-American kids have the higher rates of suicidal thoughts during this time, and also when they were looking at caregivers of people who had chronic illness, that also was a risk factor, and essential workers was high too. So this was during the first three months of the pandemic when people were also locked down. You know, when they were looking, what were some of the reasons why this was happening, they said, well, there was an increase of drinking and smoking, there was an inability to go to school, so it was increased social isolation, more family conflict, more violence in the family, so in kids we start seeing more like misbehaviors, like they were like, they had a disruption of their everyday life and their social connections, and the academic performance also went down. So we were already screening for depression, so we wanted to see what was the effect of COVID. So in our hospital, we screen anyone 12 and above when they go to a primary care doctor using the PHQ-9, and we not only do it for kids with pediatrician office, we also do it for anyone who's going to the pediatric specialists, and then we were reviewing those responses, and we were really interested in question nine, like, did you have thoughts that you could be better dead? Have you, in the past month, thought that you could have any serious thoughts of death, or have you ever in your whole life tried to kill yourself? So in our sample, we have 21,134 responses, and this is like the breakdown, so we have 16,000 white, 2,000 black, some Hispanics, it was, and when we look at the specifics, who were the people in the highest risk? And we are defining highest risk and people who have scores higher than 15 on the PHQ-9, so we saw people who were multicultural, multiracial, had higher scores on the PHQ, also black kids, and also Hispanic kids in this sample was 6.2, and female was definitely higher than male in our sample. Then when we look specifically at the question nine, right, and we start looking at the risk there, so we saw the odds were definitely higher for female, 2.78, for multiracial, 1.5, and for Hispanic, kind of like similar of what we were seeing in the CDC report, but this is like a real-life sample in our hospital, so kind of similar of what we saw that the CDC was reported, that the suicide ideation was increasing in minority, so when we look specifically at what was the impact of those first three months of the pandemic and the quarantine, we saw, we compared the answers before COVID, like the three months before COVID, the three months during the time that we have to stay home, and the three months after, and we saw that in our sample, people during those three months had higher suicidal thoughts and reported more thoughts in the past month. So it was higher in April and May. Then we look, we continue to do this screening monthly through all the time, and we saw in June, we saw another increase in September, and we think it was when kids went back to school, and it caused a lot of anxiety because they have been not going to school for so long, and so some important things that we saw in our study was that in our group, Hispanics were a little higher rate than whites, and African-Americans were also at higher rate, and women were also at higher rate. Based on that, we created a study to target everybody who were having thoughts and also scores on the PHQ higher than 12, and we're offering some CVT tools for 12 weeks when that happened. So we'll probably have data on that in the next couple of years. We hope to recruit at least 300 patients. We're doing a randomized control trial on that now. So I also wanted to talk about the impact of homelessness. So we know that one in 30 youth in the U.S. experience homelessness. Those who are homeless also have higher rates of psychiatric diagnosis, substance abuse, and the rate of suicide in this study was three times higher compared to the general population, and 65% of the homeless also experience those with housing instability have four or more ACEs. So for children, homelessness and ACEs were independent predictors of physical and mental health conditions. So we know that this impacts education, the physical and the mental health. We know that one of every five children, one of every five people who experience housing instability are children. They move from home to home. They have high eviction rates, and in this sample, like half of the homeless kids were African American. So we wanted to look in our hospital what was the rate of homeless kids too, and so this was in a period of three years. Looking at the address and who was living in a homeless shelter, we were able to identify 7,576 homeless patients. From those, 1,000 were children, and then from during that study period, 182 of those patients, so 18%, had at least one admission to inpatient child psychiatry. They had a high utilization of mental health services, four to nine ED visits a year, compared to one to two in kids who were not homeless, and had history of admissions to inpatient psychiatry. Then we wanted to look at the different diagnosis and how being homeless impacted this, so we looked at 3,478 ED visits, and we saw that in these kids, the rate of depression was higher, like the odds ratio was five times higher. Anxiety was 3.4. Suicidal rate was eight times higher in this group. PTSD, 10, you can imagine, right, like going through severe issues like this can impact how you are doing. So we think it's very important to implement initiatives across systems that support children, families, parents, other caregivers in their community, that we have to coordinate the resources across not only mental health, but social services, and healthcare systems to be able to help these kids, and what can we do as psychiatrists? We can be aware of our own role, perpetuating inequities, provide services, right, make health equity a cherished vision in our practice, develop strategies in the community that can help these children, and I think it's very important to look for social determinants of health as one of the screening tools that we should be doing in our practice, and have community resources available for our patients so we can help them. These are some potential resources, and so I think Dr. Castilla is next, and then we're going to do all the questions at the end. Thank you, Dr. Falcone, for your introduction. My name is Ruby Castilla, and I am a psychiatrist working currently in the Community Leadership Initiatives Institute at the University of Cincinnati, and I am the president of WARMI, that is an NGO that is dedicated to improve mental health in women, and I am going to change a little the lens, and to talk about the mental health disparities, and how to be a female, a woman, can impact those social determinants of health. I don't have any financial relationship, I was before employee, but I am retired from Johnson & Johnson. So basically, the objective of my presentation is to highlight the key influences of women's mental health through their life spans, including genetics, epigenetics, environmental influences of how genes are expressed, the gender-linked stress and traumas, and the reproductive cycle stages, and we will see how those factors interact to influence mental health. So we are seeing other perspectives of the social determinants of mental health. Several factors are considered as determinants of health, and complex interactions among these may have a big impact on health, and if we have a priority of women's health to achieve the four and five goals of the Millennium Development Programs, we realize the health inequalities refer to those differences in health status or health outcomes that they are associated with factors such as gender, race, ethnicity, and socioeconomic status. And we know also that the association of health inequalities with genetic and biological variables, social structure, is also another health-related factor. So we need to be aware of those. Men and women are exposed to determinants of health in different ways, have been very well established, and in 2008 the WHO Special Commission emphasized the importance of research to address the social determinants of health to identify and to determine health inequalities according to the geographical regions and group of people. So this is not new, this has been something that has been, um, we have been talking about this for a while. So sex and gender affect the likelihood of developing mental health conditions and also affect the course and treatment response. And we have to delineate a little bit here when we refer to the terminology, the sex difference, the biological base and the gender difference, culturally based, with or without biological influence. And we have to recognize that there are roles in the society that can amplify those sex differences and these influences can be accumulated across the lifetime. And we have to define that the biocultural refers to the mutual influence of biology and culture. So recent research has identified disparities between women and men in regard to risk, prevalence, presentation, course, and treatment of mental disorders. The rates of mental health condition each year in one in five women in the United States has a mental health problem such as depression, post-traumatic stress disorder, or an eating disorder. And this is the data that we have in the American Psychiatric Association. They provide the rates of mental health disorders in women and men. And you can see the majority of the anxiety disorder, panic disorder, phobias, PTSD, OCD. Major depressive disorders are more in women and impulsive control disorders and substance abuse, they are more in males. And they are the odds or the rates of major depressive disorders in women versus men. And this is based in a meta-analysis that the prevalence of major depressive disorder is almost double in women compared to men. And gender divergence in depressed symptoms begins at age of 12, also early in age, and peak at age of 16. And we are going to analyze a little bit the hormonal changes and how these can influence the results that we are going to see. So they are epigenetics and fetal programming. And Dr. Falcone provide a very good background or set up the stage for me to talk about these influencing maternal distress, their physiological changes, cortisol elevation. And these can affect the fetal genes that they are expressed. And enduring, hiding, stress response in offsprings. A chronically reactive stress response system takes a health toll physically and mentally over time. And we know that social disparities leading to maternal distress can affect the offspring health from the start. So there are many studies showing this. I am not going to talk a lot about that, but it's important that sex and gender matter in fetal programming. And there have been different results and different studies. But most find that females are more responsive to stress signals in the uterine environment. So there are changes early in early stage. And the female fetus can adapt better, for example, to malnutrition or inflammation, which this increase the survival compared to male fetuses. And has been very well determined. This may result in an increased vulnerability to, in the future, mental health problems such as depression. So we have to consider those. And these factors, rumination, that they are more common in girls. Problem solving and distraction more common in boys. Ruminative style we know that is a high risk for depression. Other risk factors for mental health problems. The women are disproportionately experienced the following risk factors for common mental disorders than men. Women are less than men. The women who are full-time workers are about one-fourth less than male counterparts in a given year. And there are very well established differences. That we are going to do something about that. I think that our next generation is going to see the outcomes of all of these efforts that we have. Probably our generation is not yet there. But we hope that in the next generation we can see more and more equality. This factor for mental health problem in women include the poverty rate. The poverty that is the rate for women is 64. And it's almost 15% higher compared with 11% for men. So 14% for women and 10% for men. For women age 65, and this is very important, increase the poverty rate is 10. While the poverty rate for men is 7%. Also there are other risk factors that we have to consider that victims of violence, about one in three women have experienced sexual violence, physical violence, and is stuck in by an intimate partner in their lifetime. And it's estimated that 60% of caregivers are women. That is another important point that we have to remark here. Females caregivers may spend a much 50% more time providing care than male caregivers. We, during the pandemic, we saw this more and more tendency to have more weight in women, in women than in men. This is another graphic where it shows the gender is linked and the influence in adolescence. Dr. Tatiana provided this. In early poverty, childhood violence, exposure to increase in leptin, increase of rates of social abuse, gonadal hormone influence in the puberty, menstrual cycle, and social pressure, sexual maturation, precedes brain maturation. And there are also the effects of steroids in the behavior. The reproductive steroids regulate many neurological functions. For example, sexual maternal behavior, eating, sleep, cognition, impulse control, and changes in this reproductive state or levels during certain reproductive stage. For example, the premenstrual phase of the menstrual cycle, the postpartum, the transition to menopause, can trigger mood dysregulation in a subset of women. And the degree of hormonal fluctuation greater than absolute or hormonal levels correlate with the mood changes and have been very well established. Hormonal flukes interact with the stress to produce mental health symptoms. And there are some graphics that are showing how this stress impairment is related with those changes. I am not going to deal because we don't have a lot of time, but patients with DMDD, they have associated increase in suicidal thoughts, plans, and attempts. There are also gender-linked stress and traumas, sexual, childhood sexual abuse, rape, sexual harassment, military sexual assault, and gender sexual harassment, inequalities and discrimination, the role of stereotyping, especially for minorities, intimate partner violence, chronic environmental strain. And under the reproductive part, unintended pregnancy or perinatal loss and reproductive coercion are playing an important role. There are other influences of mental health at perimenopause. The risk of depression are more than double during the perimenopause. And they are all the factors that they are delineated in this graphic, including the hormonal flukes, but hot flashes reduces the physical activity. Medical illness, my life is treasured, loss and role transitions, and individual and cultural attitude toward aging that they are really influencing these factors. According to a study in the WHO, there are differences in the way that women and men seek and use mental health services. There are also differences in the treatment provided. Women are more likely to be prescribed psychotropic medication than men. And women are more likely to seek help from disclosure mental health problems to their primary healthcare physician. And men are more likely to see a mental health specialist, a psychiatrist. Women are less likely than men to disclose a problem with alcohol use to their healthcare provider. Women are reluctant to disclose a history of violent victimization unless the physicians ask about it directly. And physicians are more likely to diagnose depression in women compared with men. Even both genders are identical symptoms of similar scores on the standard measures of depression. And this is also a graphic with the influence of women's vulnerability and resilience. And they are genetic, epigenetic influence, gender trauma, stress, the reproductive life stage, the gender influence coping style, cultural gender roles, and stressors related to other aspects. For example, the race, ethnicity, sexual orientation, sexual identity. In conclusion, there are barriers to access mental health care services among women. There are economic barriers, lack of insurance, costs including premiums and co-pays, that we know that they are more in the women than the men. Lack of awareness about mental health issues, treatment options, and available services. The stigma that is associated for both, for males and females, but they are associated with mental illness and the lack of time-related support, time of work, childcare, transportation. Lack of appropriate intervention strategies, including integration of mental health and primary health care services. So the interaction between the social determinants of health and mental health status might be considered in policy making. And there is a need for policies that will enhance health of women in the low education and income brackets. Gender equality is an issue of development effectiveness, not just a matter of political correctness or kindness to women. And just to mention that we have been developing a group of NGO working for, established in 2018 to improve the mental health of Hispanic, Latin American women. And this is all you are welcome to be part of. Thank you. I'm a Mac person, I'm very disengaged with Microsoft. Okay, well, thank you very much for your attention. My name is Fernando S. P. Forsen. I work right now at Massachusetts General Hospital. Teach the med school. Teach the med students, Harvard Med School. And I work at the inpatient psychiatry unit, inpatient med psych unit called Blake 11. And we get like all the med students of Harvard Med School, they get distributed between the inpatient units of Brigham, MGH and I think Beth Israel and McLean. But I get a med student every month and I work with residents as well. And in my unit, most of the patients that we see are low income, low socioeconomic status. And this is what I'm gonna talk about today. So I think Dr. Falcon talk about what happened to these people when they are children. All these social classes, differences, racial discrimination and obviously there is a gender gap that Dr. Castilla has been talking about. I get to see these people when they are 40, 50 or 60. I'm a child psychiatrist by training, but it was good to understand the developmental evolution of these people and I work in a med psych unit. So by the time I see them, they are between four, well, some of them are 25 but most of them are 30, 40, 50, 60, 70 years old and they already have a lot of medical problems. So they're in the med psych unit with uncontrolled diabetes, uncontrolled hypertension, depression, suicidal thoughts, substance use disorders. And for me, I've been working in several places throughout my life and I think it strikes me how little we talk about social determinants of health. I mean, even in this presentation, we have like 25, 27 people here. This morning I was talking to the Stephen Stahl talk on MLIs and that was like overflow, overattended. And they were talking about treatment-resistant depression. I went to a talk like three days ago or two days ago about treatment-resistant depression. And they were talking all these patients with treatment-resistant depression. We had to start thinking of using MLIs and Selegiline and we're thinking how it's important as psychiatrists that we try to see the whole picture. So, I mean, talking about treatment-resistant depression, when we're talking about somebody who doesn't have a place to live, it makes no sense at that point. I mean, calling it treatment-resistant depression. So if we look, when we were studying psychology and psychiatry, we look at the Maslow hierarchy of needs. And you know that the first thing is physiological needs, like food security, having a place to live. And these are the patients that I see, like they don't have a place to live. They have food insecurity. Then after that, you need to have financial security, friendships, love. After that, you start talking about self-esteem. After that, you start self-actualization, like self-fulfillment in life. So how can you, you know, this is kind of like the problems that we have normally as physicians. I am a physician myself. We don't acknowledge enough sometimes that we are privileged. I mean, I see sometimes I go to some talks and people say, well, you know, I'm discriminated. I have suffered. But at the same time, we have to acknowledge that me, for me at least as a physician, even if I work in an academic hospital where the salaries are lower, I am a very privileged person. And my personal struggles are more related to, you know, do I feel respected? I'm getting recognized with my coworkers. Am I doing what I really like? I don't like documentation. But we're not dealing with the problems that many of the patients that we deal with have. And sometimes we feel as providers a little bit incapable of solving the problem. So we say, well, if I can switch to an MAOI and I can help the patient, or I can start this new drug and I can help the patient, this is going to be like an intervention that I can like reward myself and say, hey, you know, I did a good job with the patient. But what can I do when the patient is homeless? I mean, technically, the solution should be easy. I'm going to help the patient get in a house, but it's really, really hard to do that. And this is what we deal with at the inpatient unit. So let me see how I pass the slides here. Oh, here. Here, okay. So I'm going to reflect on some clinical ideas from an inpatient unit where we serve primarily patients who have, in Massachusetts, you have like MassHealth, which is the equivalent of Medicaid. And I think it's pretty good compared to other states because it gives a lot of people resources. So I'm from Spain originally, and there is socialized medicine there. I think I've lived in different states, in Ohio, in Illinois, and in New York, and in Massachusetts. And in Massachusetts, I think, is where they are doing a better job of having something more similar to socialized medicine. So many of the patients that we have, they're in the unit right now. The main reason they are coming to the hospital and they are having suicidal thoughts is because they don't even have a place to live. So if you go and tell the patient, well, you know, there is serotonin, dopamine, norepinephrine, and I see physicians talking like that sometimes to the patients, but the patients say, as soon as you take care of me, that's fine, you know, you can talk about that. But what I really cared was having a place to live. We don't have, we don't know what causes depression in that context. Like, we tend to see depression as neurochemical, neurogenetics, all these things, but you don't have a place to live. That doesn't make any sense at that time. Whether you are gonna be able to, you know, take an antidepressant, like taking an SSRI is fine. You can give me an SSRI, but how are you gonna help me finding a place to live? So we have a social worker in our unit, and for everything, we have four teams. And I always, I used to go when I started working there, like, well, can we help this patient having a place to live? And they say, all we can do is give a list of shelters. So you can get a social worker in the unit, but if there are no resources in the state, all we're doing is like, I'm gonna give you a list of shelter. I was like, well, the patient will say, well, I knew that before I came to the hospital. So I knew I could go to a shelter. So I was like, well, I remember like last week, having a patient and thinking, well, is there anything else we can do? Like I was talking to the social workers, like, well, we can connect you to a case manager in the community that's gonna help you send an application for housing based on having low income. And the wait list to have an application for housing for low income is like six months. It used to be like last year. Now it's like a year or two. So you have a patient who is acutely suicidal because he's homeless. Many of these patients cannot tolerate shelters because they have been robbed or there is no security. You can be raped in a shelter. It's dangerous to be in a shelter. So many patients choose to be in the streets. So we help them connect them to a social worker so that maybe they can apply for housing and it may take up to a year. And patients, many times, they have cognitive problems, substance use disorder problems. So it prolongs their stay. And sometimes these patients are called malingers because they say, well, you're here because you just want a place to live. And we cannot do that. So I think by doing that, when we use the word malingering, which I don't, I mean, I believe some people malinger, but it's more about having really social needs. I mean, this is a patient because he's very depressed because the patient has social needs. So what we like to do as physicians sometimes is to give him medication for a psychiatric disorder. And this is what, as a physician in the medical model of psychiatry, the patient meets criteria for major depressive disorder or schizoaffective or whatever you want to put there. And you want to give medications and reward yourself if the patient is tolerating the medication and doing a good job or feeling better on the medication. And because we cannot help with housing, then we tend to say, okay, you're just here for housing. This is not my job. So you're going to get discharged to a shelter and maybe you're malingering, and I hope you don't come back. And these are the situations that we see in the ER. I work in the ER as well, in the inpatient unit. And the truth is we cannot even do much about it. And I think as a society, we have these systems of care failures that we are not addressing. Another thing that we have is, the problem is residential care. So many of the patients that we have are homeless. They are in the streets. They are doing substances. Here in San Francisco, you just go for a walk out there. In Boston, it's a little bit better, but here in San Francisco, I mean, I was thinking today, I was like, what is San Francisco's slogan for tourism? And I was in San Francisco, the city of dreams. And I was like, San Francisco, the city of dreams, you know, going for a walk here. I don't feel that way, you know. I would call it more like the city of lost dreams, you know, because if you come to San Francisco, either you have made it very well, or you will never make it. I mean, that's the feeling that I see when I see what's going on here. I see very rich people, and I see very poor people, and they live in separate worlds. And we as a society, we don't talk about social class. I don't know, as somebody who comes from Europe, I think when I came to the US, I realized that we were not talking about social classes. Like, we talk about other ways of feeling discriminated, but we are not talking about social classes. I don't know if this is related to the fear of communism that it was in the 60s, I mean this is just personal ideas, but it's clearly, it makes an impact, the social class in social health. And I remember there was an article in the 70s that said, if you have schizophrenia, you are poorer, and they sent that article here in the US, it was interpreted as, no, no, no, being poor doesn't make you schizophrenic, it doesn't increase the risk of schizophrenia, it's like schizophrenia makes you poor. And in Europe it was interpreted differently, it was like, no, no, no, being poor and having no resources increases the chances that you develop schizophrenia or psychosis. And this is something that empirically we see, but we still don't embrace that being poor can put you at risk for schizophrenia, when in the present it's so obvious, like being poor is going to put you at a higher risk for having depression, but we don't want to embrace it in schizophrenia, because in schizophrenia, we like to see schizophrenia as a biological condition that is probably related to neurogenetics that NIMH or somebody will figure out, and then, you know, that's the way we're going to treat it in the future. We're going to be, we have been to many talks here that they say, which is, they are very interesting, I don't want to diminish these talks, but it's like, in the future, psychiatry, the psychiatrist is going to be like a rheumatologist that is going to order like some labs, he's going to see some patterns, biological patterns, and we're going to find the right pill with pharmacogenetics that is going to fix somebody, and we're not thinking about all these things of social classes that are really making an impact in the way that people are suffering. I mean, mental suffering is a real thing, and we have all these diagnostic categories, but we know, I mean, all the research that we see is like being poor actually make you have a much higher risk of having trauma, having schizophrenia, and we are lacking the resources to do something about it. At an individual level, when you're having a private practice, you cannot do much about it. I mean, especially when you're working in a cash-only private practice, because many physicians, another problem that we have, get burned out with documentation, because many agencies are like, we need to show that we are doing a good job, so for that, we're going to put all these checklists of documentation, and we're always documenting, and there is less and less time for patient care, and people go to cash-only practice, and we have this reductionist view that mental health or suffering is just related to having depression or treatment-resistant depression, where you have to use other psychopharmacological agents to help people. So I think it's important that we also talk about social class. I'm not trying to do a communist revolution, I'm just trying to be fair. I mean, it sounds like it's playing a role here. The length of a stay is very prolonged when people are homeless. They are going to continue to say that they have suicidal thoughts, people are going to get anxious, they are going to be called in, patients are probably malingering because they have been three days here, and they still have suicidal thoughts after I changed the meds, you know, so probably the patient is malingering because they just want a place to stay. I mean, those things you're going to hear all the time in the inpatient unit. Then we discharge the patients to the streets very often, and we know that. We just say, hey, you know, like, you're no longer meeting criteria, you told me you're not suicidal, because if the patient says that they are suicidal, they put them on suicide precautions. And nobody likes to be on suicide precautions, because everybody is very scared that somebody commits suicide in the unit, and they are put on liability, all the liability that that generates. So the patient says, no, I'm not suicidal here, I feel safe, but you discharge me, I think I'm going to get suicidal, because I'm homeless, and they're like, oh, that's malingering, so you're going to get discharged. So we discharge patients to the streets. I mean, this is something that happens every day, we just discharge them to the streets, and then I see them. I live in Boston, so I live there, next to the hospital, and I just see them. Before I came here, when I was going to the airport, I saw two of my patients walking around high on something, and I had no idea where they were going. So when we try to, when we have patients with genuine severe psychosis, then we say, well, we cannot discharge them to the streets, because sometimes they are agitated, or they are dangerous, but we cannot keep them in the unit, because we're getting pressure all the time to shorten the number of days in the patients, and you get reward for discharging people quickly, and do the quick turnover. And we say, okay, we want to find a state hospital, at least they can be there for a few months. The wait list for a state hospital right now in the inpatient unit is six months. So we were able to put two patients in a state hospital, and the patient had to be waiting six months in an inpatient unit where there is no fresh air, where there is all the high risk prevention, just because we couldn't send them to the street, because they were too dangerous to be sent to the street, and they had to be waiting like six months in the inpatient unit. So these are things that we are not addressing, and this is going to play an impact in the outcome. When we talk about asylums, people don't like that, because in the 1950s, in the asylums, they were unfunded, there were not enough psychiatrists, and the patients were mistreated, and then we thought that with assertive community treatment, we're going to help these people, because now we have the right meds, that are the same meds as effective as the one that we had in the 1950s, but we thought they were better, because the pharmaceutical companies were telling us that they were much better, and we thought, well, with assertive community treatment, they're going to be integrated in the community, and we're going to do a better job. And it's possible that we do that. I mean, there are some groups, like Soteria, that started in California, and now they are doing trials in England, where the community is really helping the patients, but right now, because of the stigma with mental health, it's even perpetuated by psychiatry sometimes. It's very hard to integrate a patient with schizophrenia who is homeless and has no family in the community in the United States right now. When I was a psychiatry resident in Cleveland, Ohio, I remember I was living in a building that was all welfare, because I had just come from Spain, so I didn't have money to pay for rent in a nicer place, so I was living in a welfare place for the first year, and my neighbor downstairs had schizophrenia, and she was yelling all night, and she would wake me up, and everybody was like, oh, my God, how do you have a neighbor who has schizophrenia? You need to move out of there right now. These are all my co-workers, psychiatrists, were telling me, you need to move out right now, you know, because you have a neighbor who has schizophrenia. So these are things that we don't integrate, like we are fighting stigma, but then when we see the homeless person with psychosis in our community right now, that person gets existentially non-acknowledged, I mean, it's completely living in a parallel universe. We stay away, if they're approaching to us, we think they're smelly, they're going to ask us for money, maybe they are dangerous, and they are not even acknowledged. I mean, you may cross the street, and this is something we all have done, I mean, like, or at least I have now, and we have to think about that, because it's really going to make an impact. We don't have residential care for people, the state hospital is six months, but also when you go to the state hospital, it's considered an acute unit, like, we don't have a place where people can live just because they have chronic severe mental illness. So it can be an open unit, maybe you can put more money, you don't have to do the asylum of the horror movie where you just lobotomize people, but is there an option of residential care, or these patients, do you think they are safer in the community, discharging them to the streets? Just go to, for a walk right now in the streets of San Francisco, and you think these people are safe, you know, you arrive to your own conclusions. Minorities is something we have talked about, and I think in the U.S. now there are big efforts to address the difference between minorities, but, I mean, I get a feeling that working in a relatively elite hospital, that they put a lot of campaigns, there is a lot of speech, there is a lot of, you know, ideas, they create a lot of groups, but the changes sometimes don't happen, like, in my department, most of the physicians are white American physicians, many of the minority residents that we, for residency, we try to, they try to do more, a percentage, to have a better balance of minorities, but most of the minority residents, when they graduate from the program, they don't want to work at Massachusetts General Hospital, they offer them jobs and they just go somewhere else, because they feel they haven't been treated well, I mean, this is, no matter how much we are making an effort, we don't realize that they don't feel the same way, even if you are giving, you are saying the right thing all the time, it does, it's not that important, I think we put a lot of importance about saying the right things, you know, I'm going to tell you the right things, I'm going to tell you that I really care about you, and I'm, but you have, you know, the message that your body is giving is different, you feel people who are different as foreign, and you treat them differently, and you don't realize that, even if you think you are saying the right things all the time, so, and I think this is something that the reason why many minority residents don't want to stay in the hospital as well, and with the patients it's the same thing, I mean, there are language barriers, for example, I work a lot with Hispanic, Spanish speaking patients, and in Boston we have a community, we started a clinic now, a Hispanic clinic, the, in the community, many of the patients they speak Spanish only, and there is a lot of misinterpretation with the translation, I think there is a, we have to work with translators better, because I think there is a misdiagnosis all the time, like, the patients, sometimes they have low education, they don't understand English, and they really want to get help, so, as clinicians, when you go with a translator, you ask the questions, like, are you suicidal, are you hearing voices, and the patient all the time is going to say, yes, yes, I need help, or I don't even understand what you are talking about, so, and they get diagnosed with severe mental illness when they don't have it, they get misdiagnosed, they get misdiagnosed often, they get more misdiagnosed with severe mental illness, also they, the trauma symptoms, they are not addressed, substance use problems are not being addressed, and I've seen people with alcohol use disorder that are causing hallucinations, and they get diagnosed with schizophrenia and they ignore the alcohol problems, and I think this is something that happens when there are language barriers, and we, I've witnessed that as a Spanish speaker, because I see them, then I see the patient, and I say, well, I think they didn't get it right, I imagine with other populations, like the Asian-Chinese population that we have in Boston, it's the same, like, for me, when I'm getting the translator, I feel I'm not getting it quite right, we don't have enough providers, I mean, in my department right now, I'm the only person who speaks Spanish, seeing patients, and we have like 200 psychiatrists there, so this is something that is affecting patient care, I mean, people are discriminated, they feel they are being treated different, if our residents are feeling that way, imagine how the patients are feeling, so in our unit, they did a study two years ago, one of the residents, and they saw how many physical restraints were used by ethnicity, and for African-American, it was like three times more, so when I saw that result, I was like, hey, let's talk to nursing, let's talk to the unit director, and every time I had an African-American patient, I was really checking myself, okay, the patient is going to want restraints, I really need to make sure that I'm not making, that there is a clear reason, I didn't see so much of a difference in the rest, it's like, everybody's like, oh, that's terrible, you know, I think we had to correct that, but we were not, it was not happening, like, people were going into restraints more, and they were like, well, sometimes they are more dysregulated, or they are more aggressive, I was like, well, people get more aggressive and dysregulated because they have suffered more discrimination and more trauma than the other patients, so you had to think about that, you know, not just the shortcoming clinical picture that you're trying to treat, you know, so these are things that we don't think enough about, you know, and we all, I mean, have to think about that. Let's see, I go to next slide. What do I have, oh, here, sex trafficking, another thing, we, I mean, I always go back to the same thing, like, we like to say the right things, oh, sex trafficking is horrible, we need to stop sex trafficking, well, if you look at the wider picture, many of the patients that we see in our unit, they have opioid use problems, a lot of trauma, difficulty getting a job, difficulty finding a place to live, so if they are doing sex trafficking, they are doing it for survival, so when you go there, it's like, oh, wow, these patients, many of the patients don't want to tell, actually, that they are, you know, like, doing sex working, that they are sex working, they don't want to tell us because it's illegal, so they can get in trouble, they think we can report them and they can go to jail or they can be arrested for that, but even when you say, well, no, it's not illegal, you're being a victim of sex trafficking, how can the patient show or prove that he's being a victim of sex trafficking when the patient sometimes is just, you know, I need my drugs, I need a place to live, so, nobody's going to hire me in this condition, so sex trafficking is my way to survive right now, so we have all these, we refer them to agencies that are trying to combat sex trafficking, but these agencies, or they're going to give you resources to report sex trafficking, but they're not going to give them money or get them a job, so the patients, we discharge them doing our checklist, like, we did a good job with that, but we know that these patients are going to go back to the streets and they are going to continue to do sex working, so when we say, this is treatment-resistant depression, so they consider starting Abilify, in these situations where, like, adding Abilify to the SSRI, the patient's going to be like, sure, you can do that as soon as you give me a place to live, or something like that. Okay, next slide. Immigration, you know, myself, I'm an immigrant, but I came here to be a doctor, so, but it was not easy, I mean, I went through all this process, like, I don't know how many visas I had got already, I've been 15 years waiting to get a green card, and imagine a person that comes with nothing, like, people are, they don't have any legal documentation, they are not citizens, they are not eligible to anything, so they can get admitted if they are suicidal, but all the immigrants that we have from Salvador or from Mexico, when we try to refer them to a place, there is nothing, there is only, we created a new, in the hospital, a new place to help immigrants that they can call, and they can give them advice, but that's it. We have a place called Casa de la Esperanza in Boston that, for the Hispanic people, they can connect them to resources, but they can connect them to an appointment with a social worker, possibly they can get a primary care provider, but a psychiatrist, for them, is like, well, you know, they are not going to get a psychiatrist, and many of them are not going to be able to navigate that, so many of them cannot read in Spanish or in English, so the resources are so limited, we have only one place that we can refer patients who are immigrants without documentation or without being a citizen. We have only one place, so, and that place, we knew about that place because we had a Dominican resources specialist who found the place, and we're referring everybody there, but I don't know how many people are referring there, but the wait list is becoming longer and longer, so it's very difficult, and sometimes you just discharge them back to, you know, they are just going to go back to whatever they were getting, so in the inpatient unit, when you are doing the acute intervention, you know that that's the last treatment they are going to get, like, whatever advice you can give them, it's the last time they are going to see a psychiatrist, and I know that, I know that, so I try to pay a little bit more time and effort in these spaces, because I know they are not going to see a psychiatrist in a long time after they see me, so another thing we are trying to do is connect them to churches, so we go to the local churches, and people are like, hey, we are psychiatrists, we don't send people to churches, but when you go to church, you can get food, you can build community, other people can help you, so I've been sending people to churches, to the church, just to get food, and try to talk to a pastor for psychotherapy, and they find it helpful to talk to someone, to a pastor, and it's a form of psychotherapy. Refugees is even worse, because these people come with trauma, so we get refugees for all the conflicts. We get people from the airport as well, all the time, directly here to our unit, but we have a clinic for refugees, or somebody doing assessments, but the same problem, like you do assessments, but then there is only one or two agencies that can work with the patients. It's very difficult to find resources for them as well. We get many patients with mental illness, it's associated also with discrimination, or being gay, or belonging to the LGBT community, and I think we are, you know, in the hospital things change, but what I see a lot of times is that patients go by, they use the pronoun they or them, and there is still a lot of difficulty, I mean, we are trying to, all of us, trying to learn ways of being less offensive when we use words, but obviously there is a lot of trauma, a lot of discrimination, and a lot of progress has been made, but we continue to have more patients that suffer trauma, belonging to the LGBT community, because of trauma that they suffer early on in their life, or they continue to suffer, and patients who are transitioning are very often coming to our units, trans men, trans women, coming to our unit because they have suicidal attempts, suicidal thoughts, and it's a very high risk factor for depression, and suicidality as well, and when we are talking about women, the same, when you are homeless, and you are a woman, you are very, very, very high risk for being raped, being sexually assaulted, so many women who are homeless, they have to dress like men, so we give them clothes, and they prefer to get, we have, in our unit we have created a section for people to donate clothes, and we all donate clothes there, but we give them male clothes, because if they shave their head and they wear male clothes, they get a much lower chances of being assaulted, and that's what we see, I mean, you pay attention here, you're going to see many women who dress like men and try to look like men to, you know, have less chances of being assaulted. Veterans as well, they have severe post-traumatic stress disorder, the VA usually is not enough, and we have many veterans, another social factor that affects depression, we don't talk about, and PTSD. And substance use disorder, we live in a severe opioid epidemic right now, I mean, it's, and as a society, we don't know what's the right way of dealing with this, we know that in countries that there are no opioids, there is no opioid use disorder, but now we have medicalized opioid use disorder in some sectors, and we think, well, opioid use disorder is like diabetes, like you need Suboxone or buprenorphine to keep maintenance and keep this chronically, but we don't know what are the long-term consequences of this sometimes, we know that the short-term is better when you're on maintenance treatment, for many of the patients that can get jobs and can be functioning, but the patients that we see in the inpatient unit, they have tried Suboxone already like four or five times, they're now on methadone, and we put them on opioids, but I don't know in the long-term, what's going to be the best solution for the opioid pandemic that we're dealing with, I don't know, I mean, this is more questions than answers, but we know that by the end of the month, many patients run out of money, and they get admitted more often if they have opioid use disorder, and they don't want to go in withdrawal, so they go in withdrawal, they get suicidal as well, but then they say, well, you just need a dual diagnosis program, you don't need to be in an inpatient unit, but sometimes they have to wait in the yard up to a week finding one of these programs, so we have many of these patients waiting for a week just to get a program, and then we put them again on Suboxone or maintenance treatment of methadone, and we discharge them back, but they keep coming back all the time, so I don't know, I don't have an answer about how to solve this problem that we have with opioids, but it's making depression, suicidality, and vulnerabilities, it's enhancing like tenfold, and sobriety or maintenance treatment seems to be like a short-term good solution, but I'm not fully, personally, I'm not fully convinced that opioid use disorder is the same as diabetes, I think it has other level of complexity. Okay, so this is all for my presentation, thank you very much, that's my email, and I think now we have some time for questions. Anybody wants to make a statement, a question, or share an experience? Well, I guess more in the line of a comment, because I had just come from a talk by Professor Griffith on dignity, and he talked about two types of dignity, intrinsic dignity, which would be just by the fact of being a human being, we should treat each other with mutual respect, and sort of attributed dignity, which is the one, you know, it's like us and them. I mean, so it can be done negatively, or it can be done positively, you know, giving persons awards for having done good things. So as I was listening to your last presentation, in terms of dealing with the homeless, and with the sort of minorities, and so on, it's very much that sense of dignity that's not, I guess, being demonstrated, it's more attributed dignity, where it's like, you know, it's those other people there, as you said, they may be your patients in one setting, but then in another setting, yeah, you know, you don't want them as your neighbours. And so I just thought it was quite interesting to think of it in terms of the dignity, and it's something that we all have to be, I guess, aware and conscious of, and think about it. Yes, a very good point. Thank you for your comment. Yeah, I mean, I agree 100%. Yeah, living with dignity. I used to work in cancer hospital before, in Sloan Kettering, and we had a therapy called dignity therapy, because, like, living with dignity, dying with dignity. And this is something that we talk a lot about in palliative care settings, but living with dignity as a psychiatric patient is something that I think you're bringing a good point here, that here in San Francisco, I mean, it's so dramatic, like, I'm here walking around and seeing all these people living in $5,000 one-bedroom apartment, and downstairs you get a homeless person that everybody's like, oh my god, this is dangerous, San Francisco. I don't want to be walking around San Francisco. You can step on feces while you're walking around San Francisco. And the contrast is so big between the two that I was thinking, yeah, living with dignity is something we don't even contemplate. Hi. Hi. I just want to say, first, I'm happy to hear the awareness and to kind of make sense of why I see this recidivism of patients. I work for the Department of Veteran Affairs, of our veterans coming in homeless over and over. So it's great to have a name, the social determinants, that this is just part of where they are, who they are. So that makes sense for me, and thank you for that. But I was in a class the other day, and it was psychiatric diagnosis, do race and ethnicity still matter? And so to hear these two, where racism does exist, and sometimes people aren't even aware, to hear that and to hear it on this platform, that it's just not me that see it, that observe it, but that it truly exists. So thank you for that. I really appreciate the awareness that you have brought about that. Thank you. Thank you. No, I think that it's so important. I think Dr. Renato Alarcon was talking yesterday about the physical reductionism that we have in psychiatry, because we are pragmatic. So you want to build your clinic, and the insurance, well, lack of insurance is something we have talked about as well. But if you do cash only or the insurance, you're going to build based on using medication in the medical model. And if you don't prescribe medication, then it's not a medical intervention. So the coding goes from 3-3 to 3-2 or 3-1, as soon as you don't give the medication, because it's based on medical complexity. In this medical model, all these psychopharmacological drugs are the most popular. But if we think about it, what is playing a bigger role in depression? Homelessness, trauma, social determinants, discrimination, or a chemical imbalance that we haven't figured out yet neuroscientifically. So when we think about treatment, it's just because we lack the resources. We just provide what we can actually do in the clinic, and that's how we want to see the world. But that's not necessarily how the world works. Hi. Oh, that's loud. Thank you so much for your talk. I think it's really important, and especially in a lot of medical education. I'm a medical student at USC. We're trying to emphasize more education surrounding social determinants of health, because we know those are inextricably linked with so many chronic health conditions, mental health conditions. And I've been doing a lot of mutual aid work in Los Angeles, meaning that work in the community, social determinants of health, that social part is being part of the communities. The work with organizations, working with churches, collaborating, that is a lot more accessible for a lot of people than getting into a hospital setting, getting connected with necessarily, say, like a social worker or an organization with a wait list that's a year long, two years long. So I guess the question is, all of you work in academic centers. How do we make that connection? How do we promote voices from within the community to work in these centers so that you can have that connection between, say, people who are leaders in homeless work who may have experienced homelessness themselves, but that's more connection for someone who is experiencing homelessness currently than, say, a professor of psychiatry who has never once lived under the poverty line. So how do you make those connections, and how do you advocate for more of those community members in academic settings? Partnerships, right? Partnerships are key, partnership with all the community organizations like NAMI, going to all the different community events, right, helping, you know, as much as you can, sometimes even in your own time volunteering for these places and building a relationship with the different communities so then you start decreasing the stigma about getting help. We have, in addition to Dr. Falcone's point, the collaboration with different institutions, including the same level in the city where you are living, there are many academic institutions and between them you can build relationships, but also with the community members that they don't have probably the same level of education that you may have. They don't have, they are leaders in the community and they need what your expertise, you are the expert, the subject matter expert in some of these conditions in the diagnosis, but if you partner with them, if you can work together, this is something that we need to promote in order to be more, to treat better the patients that we have, definitely, I don't know. Thank you. The awareness as well, to be, to talk about these things is important, to be aware of those issues and that it is, issues exist, yeah. Well, thank you for being here today.

social determinants of health

mental health disparities

prenatal care

cultural experiences

racial disparities

women's mental health

socioeconomic status

systemic barriers

homelessness

community partnerships

policy intervention