All right, welcome everyone. We're so pleased to have you join us at our session this morning. We know it's early. We're really grateful you woke up early to get here. And our session is titled, Fighting for our Future, the Effects of Anti-Asian Racism and the COVID-19 Pandemic on Asian College Students and Asian Medical Trainees. And just want to introduce ourselves. I'm Dr. Amy Alexander. I'm a clinical assistant professor at Stanford University. And I also direct the Student Mental Health Fellowship. Also involved in the College Mental Health Caucus here at the APA. And also will be the incoming president of the AWP, which is the Association of Women Psychiatrists, which also meets here at the APA. I'd also like to introduce my colleague, Dr. Joan Deng. She's also a clinical assistant professor and the co-director of the Stanford Asian Mental Health Clinic, also at Stanford. And completed her Addiction Medicine Fellowship and works in addiction medicine. And has been a wonderful colleague in helping to run these studies and getting grants and working on them with me. Also like to introduce Dr. Rishabh Gupta, who's a staff neuropsychiatrist at Brigham and Women's. And is an instructor in psychiatry at Harvard Medical School. And finished your neuropsychiatry fellowship recently. And then finally we have Donna Tran, who is a third year medical student from Michigan State University. And is the immediate past president of APAMSA, which is the Asian Pacific American Medical Student Association. And has done lots of things for Asian mental health advocacy and we're just so pleased to have Donna join us here today as well. We have no disclosures and this presentation is one of the designated work products of the APA's College Mental Health Caucus. We want to include a trigger warning because we are discussing anti-Asian hate and violence. That we will be discussing these themes, which may include violence, racism, and mental distress. And the graphic or intense content may be emotionally and intellectually challenging. Here's our learning objectives for the day. I don't think I'll read through all of them, but we hope that you will have a better understanding of Asian mental health, Asian student mental health, the effects of the COVID-19 pandemic, and also to get a glimpse at some of the studies we've been doing and what we have found so far. So we'll have a couple of presentations, then we will do some small group work together, and then we will finish with some Q&A. So I believe that this is probably the poll question that you answered, and so if you haven't already, please go ahead and capture the QR code with your phone. And we can start putting the poll results up, I think, Donna, we could switch over. And our first question, the results are coming in. Have you worked with any clients who have suffered from anti-Asian discrimination? And it looks like in this room right now, about 80% of us have, and that is a large number of, that's a large percentage of people to be working with patients who have specifically suffered from anti-Asian discrimination. Okay, and then I think we're ready for our next poll question. Go to the next slide, okay. Okay, here's our next question, so it should pop up on your phone or if you need to capture the QR code again. Okay, so our next question was, have you experienced anti-Asian discrimination or know of someone who has? And it looks like almost everybody here who has answered the poll has. So, all right, so we will continue. Okay, so now Donna and I will be presenting on college mental health, COVID-19 and anti-Asian racism and discrimination. So we will start off with some demographic information. There's definitely been an increase in demand for mental health care on college campuses even pre-COVID, which has increased even more since the pandemic. And how many people are we talking about? We're talking about almost 20 million college students as of 2020, 58.6% are women, and that's important to understand because we may talk about intersectionality issues for people who are women and Asian because there's specific challenges with that. Percentage-wise, 6.7% of students are Asian, which is about 1.3 million students, and 0.2% were Native Hawaiian and Pacific Islander. Sometimes those categories are linked together, but we've pulled it out a little bit because that particular population has additional challenges being of an indigenous people and something that other Asian subpopulations don't face. And then there are also a million international students, about 5% of our student population, and that is also important because many of those international students often come from Asian countries, and also have specific problems and challenges as well, especially with acculturation issues and isolation and just lack of supports. In the COVID-19 pandemic, when surveyed in the fall of 2020, and just as a reminder, the pandemic, and when things shut down here was March 2020, almost three quarters of college students were home and doing college from home and not on campus anymore due to the pandemic, which is unprecedented. I don't think we've ever had anything quite like that before and so disruptive. The mental health effects have been great. Some of them that were described include younger adults and racial ethnic minorities in particular report disproportionately worse mental health outcomes, increased substance abuse, and elevated suicidal ideation. Also compared to fall 2019, the prevalence of depression in college students increased in the spring of 2020. And in March through May 2020, a higher proportion of college students reported that their mental health negatively impacted their academic performance. And in addition, if you remember also in 2020, there were significant race-based incidents that happened, including the killing of George Floyd in May 2020. So also questions were asked about students witnessing race-based discrimination, and 40% of students had. And of course, in addition to what we're just, topic of discussion today, which is the increase in anti-Asian hate and violence since the pandemic started. Asian students also just as some other statistics about this particular population, Asian students had the lowest prevalence of treatment with roughly 80% of cases being untreated, and 23% experienced perceived stigma affecting their ability to seek care. We would like to play this video. On March 16th, 2021, six women were among the victims of a horrific shooting in Georgia. They were grandmothers, mothers, daughters, sisters, and wives. They were killed because they were Asian, but anti-Asian violence is not new. It is part of our collective memory. As the families in Georgia mourn and memorialize the lives of their loved ones, we remember the history of racism our community has faced. In 1875, the Page Act passes banning Chinese women from entering the United States. It's the first federal law to limit immigration. In 1882, the Chinese Exclusion Act passes prohibiting Asian immigrants from becoming US citizens. It's discriminatory practice has survived for over 80 years. In 1885, 28 Chinese Americans are lynched and murdered in Rock Springs, Wyoming. 1930, across California, hundreds of Filipino American farm workers and scores killed by rioters. 1942, 120,000 Japanese Americans incarcerated in concentration camps by our own government. 1982, Vincent Chin beat to death by two men with a baseball bat right before his wedding, mistaken for being Japanese, accused of stealing their jobs. 1989, five Vietnamese and Cambodian children killed more than 30 wounded. Stockton, California. In the wake of September 11, 2001, attacks against Muslims and South Asians surge. 2012, six Sikh Americans killed in a temple in Oak Creek, Wisconsin. This past year, almost 4,000 incidents of anti-Asian violence, including murders of our elders simply walking in their own neighborhoods. Memory is the antidote to death. Solidarity is the answer to silence. As activist Valerie Kaur once asked, what if this is not the darkness of the tomb, but the darkness of the womb? Today, we birth something new, knowing it's up to all of us to keep each other safe and shine a light together. Okay, so we thought that that was a nice summary of just anti-Asian hate and discrimination that has happened in the history of the United States and has spanned centuries, actually. And to give due attention to this topic, we really feel like you have to go back and understand the history of what has happened in this country and the treatment of Asians, which was very poor at times. And so here is a timeline, which kind of captures some of the things that were discussed in the video, but some things to point out is there was a Chinese massacre in 1871 in Los Angeles. Again, they mentioned the Chinese Exclusion Act, Japanese internment camps. And there was a series of anti-immigration legislation as well. So just many, many things. And when you thought things couldn't get worse, they suddenly have with the COVID pandemic. So go to the next slide here. So just as a timeline, that green square bubble at the top, so just as a reminder, the end of 2019, China reports pneumonia cases of unknown cause. And then there's a scramble to figure out what it is because it ends up being deadly for a number of people. And then in January, 2020, the genetic sequence of the new virus is released. It's found to be a coronavirus, a novel coronavirus. And in January, other countries confirmed cases as well. Then the WHO declares a global emergency. And then in February, I wanna bring some attention to what happened in February. The virus is named SARS-CoV-2, and the disease is named COVID-19. And a lot of why it wasn't called the Chinese virus or Wuhan virus, that was deliberate on the attempt of the WHO, that they already anticipate that you cannot name viruses after countries or people, animals, that it would bring about problems, discrimination, violence. So it was intentional to give the virus a neutral name. And so it was very, very disconcerting to many of us in March when we saw that the president was naming the virus, the China virus or the Wuhan virus. And we just knew that that is not a positive thing at all coming from someone from leadership. And then that was followed by an immigration ban in April of 2022. And so this is really the setting in which a lot of anti-Asian hate and discrimination then came up. And so since March of 2020, over 11,000 incidents have been reported to stop AAPI hate, which is a website that has started by Russell Jeung. And he has been collecting all the incidents of this. And that is just a lot that some of those cases are quite violent. Some of it is harassment, it's threats, it's intimidation. And we just wanted to put this website up here so that people know. One thought to have is that if you're working with a patient and they have undergone violence like this and they're asking what they can do, they could actually report it on the website here. And that's helpful because we're trying to collect all these incidents. Okay, some concepts also we want to review that describes anti-Asian racism and discrimination. Because sometimes these concepts, you may have heard them thrown around, but may or may not be totally clear about what it's referring to. So sometimes you'll hear the model minority myth. So what does that mean? Well, that means that Asian people are stereotyped as a group, often as studious, successful, smart, a population that has achieved, quote, the American dream. And that unfortunately, it's a concept that often is pitted against other racial minorities in that people tell those minorities, you should be like Asian people and be successful and smart and achieve the American dream like them. And so this is a problem because it creates divisiveness amongst minority groups, but it's also a problem because not all Asian people experience these qualities. They don't necessarily feel successful at school or smart or all these stereotypes. So it just does not describe all Asian people in the United States. And it's very harmful, especially if someone feels like this really doesn't describe them, but this is what's expected of them. Yellow peril is a racist color metaphor that depicts people in the East and Southeast Asia as an existential threat to the Western world. And sometimes this is used for legislation that this is, you know, Asian people are threatening so we better pass some laws so they can't harm us any further. Perpetual foreigner is a racist, xenophobic form of nativism in which naturalized and even U.S. born citizens are perceived by some members of the majority as foreign just because they belong to a minority ethnic or racial group. So basically, even if you are born in the United States, you were not born in an Asian country or overseas, you're constantly viewed by the majority as a minority and not American or yeah, not from here. Invisible Asian is a term that, and referring to the expectation that Asian people will be quiet, that they will not cause problems, that they will stay in line and not complain. And also is a reason for excluding or marginalizing Asian people as well. And so a lot of Asian experiences is that of feeling invisible or not feeling seen, not feeling heard, not feeling like your needs are attended to. The bamboo ceiling refers to the challenges that Asian people face when moving up the career ladder and holding positions of power and leadership due to not being part of the majority group. The ceiling ensures that Asian people as a group will not hold leadership positions. And again, part of the invisibility will essentially stay quiet and non-threatening as a group. So again, I just want to review some of these terms that often come up. Key findings from the Stop AAPI reports include that Asian-Americans who have experienced racism are more stressed by anti-Asian hate than even the pandemic. One in five Asian-Americans who have experienced racism display racial trauma. Asian-Americans who have experienced racism have increased depression, anxiety, stress, and physical symptoms. And experience of racism during the COVID-19 is found to be more strongly associated with PTSD symptoms. I mentioned intersectionality earlier, just so you understand how many students we're talking about. And again, these numbers are showing actually that more women are attending college than men currently. But women are often, women as a group, not just looking at women, women are often victims of violence with one in three women reporting physical violence from an intimate partner. One in four women experiencing severe sexual abuse or severe physical violence, including beating, strangling, et cetera. And one in five women experience sexual violence. Women students are often the victims of violence as well. 13% non-consensual sexual contact. 24.8% of students reported sexual assault and sexual misconduct that was very or extremely problematic on their college campuses. And 15.9% report having the experience of being sexually harassed. And then even women in medical training, 59.4% of medical students and trainees have experienced harassment in training with more women than men reporting this. Okay, so I am going to hand it over to Donna. Hi everyone, just wanted to present on another Stop AAPI Hate youth report. And I thought this was very interesting because they were surveying youth who will become these young adults and college students and medical students that we all try to help in our certain population. And so for this, they were looking at basically trends in discrimination during this pandemic time period. And they found that youth were more likely than adults to be harassed at school, 16.7% versus adults at 1.8. And then online, a similar statistic as well, 16.7 versus adults being online, 10.1%. This just shows how youth are more likely than adults to be severely impacted during the pandemic. Girls were 2.5 more times likely to report than boys, which also reflects the general population as well. When they were surveying just anyone over 18, it's the same kind of statistic as well. And then this I found was really interesting. So adults were present in almost half of anti-Asian cases that involved youth. However, only about 10% of those adults actually intervened just in any way, right? Either saying something or taking some action, which I found was quite frankly, very shocking. And so for youth, they've been severely emotionally impacted when surveyed, 73% expressed a lot of anger and frustration, 60% of frustration, 23% of fear, and then almost half for sadness and depression. They said that at schools where AANHPI students face higher rates of bullying as compared to other racial groups, students frequently lack the cultural and relevant support. And this kind of harassment and lack of support then affects their academic performance, which then also affects their social life, affects their family life. So it has this kind of rippling effect of where it starts in public, in schools, and without that kind of support that they are needing in a culture aspect, it really affects certainly every aspect of their life. This was taken in the summer of 2020, so I'm more interested to see after a few years, kind of what has happened, what do the numbers look like now, right? Has it gotten better or has it gotten worse in the landscape? So to work a little bit for the federal government, so I'm really proud of all the numbers that they run. And so SAMHSA is actually gonna be here presenting later today, the director of it, but just wanted to show here, basically from 18 to 25 years old, any clinically diagnosed mental illness in this population spiked up significantly. And you can see there that for 18 to 20 and 21 to 25 year olds, they are the highest number of percentage out of any age group to have any mental illness. So truly within their young adult 20s and early later teens is when it starts kind of manifesting. And for here, just also wanted to show that again, 18 to 25, you can see any mental illness from 38.9% to 42%, and then down, they also break it down by genders and then different races and employment status. But here you can see for ANHPI, for receiving any mental health services, Asian American groups were the only ones who actually went down. Every other different racial and ethnic group actually increased their utilization of mental health services. And even more shocking is that NHOPI, there's not even enough numbers for SAMHSA to run stats on. So it doesn't even exist. So that kind of lack of data really hurts our efforts to try to disaggregate the data. There's not even any numbers, right? Native Hawaiian and Pacific Islanders, sorry. Thank you. Okay, and then back to you for the recognition. Okay, so the University of Michigan collaborated with other organizations, including the Steve Fund to look at the problem of addressing Asian student mental health needs on college campuses. And they came up with a list of recommendations. So we wanted to summarize those, that campuses should elevate the cultural competence and probably cultural humility of the university at large. They should also conduct Asian student and faculty needs assessments for their particular campuses. And they should also provide physical and educational spaces for Asian students to be known and affirmed. Also, we wanna make the comment that various cultural subgroups, the Asian population is very variable. And different subgroups are racialized differently. And so they also specifically highlighted the experiences and the needs of South Asian students, including Sikh Americans, as well as Pacific Islander students. Another finding is that not all AANHPI college students identify as AANHPI, and that's something to take into consideration as well. Also, other statistics to know about is that suicide is the second leading cause of death for AANHPI young people. And again, as we mentioned earlier, this is the group that's least likely to seek out mental health services. And as with all racial trauma, the racism experiences are physically and psychologically harmful. So I just wanted to give a quick view from a medical student perspective about tackling COVID-19 racism and mental health. So for 2020 to 2023, for the past two-ish plus years, I was the national president for the Asian Pacific American Medical Student Association, short for APAMSA. One of my colleagues here was also there as well, and another one here, Mr. Justin, was our advocacy VP too. So I just wanna give a quick shout out to that. This past March, we had our 29th national conference, and we actually had the founder of Stop AAPI Hate come and present. His name is Dr. Russell Jung, and he talked a lot about the themes about anti-Asian hate, the yellow peril, and really how healed people can heal people, and how restored people can restore people. So that was really his big overarching theme about how we can come together to heal together. You can see there, we had workshops, we had students come by, so it was really an amazing event. And here, I'm going to play a little snippet. The co-founder of Stop AAPI Hate visited OHSU earlier today. The nonprofit tracks and works to prevent hate and discrimination against Asian Americans and Pacific Islanders. Now, during today's visit, the nonprofit leader spoke with the Asian Pacific American Medical Student Association. Hundreds of medical students and health professionals came to the event, and he urged listeners to be aware of the issues that Asian Americans are facing. Sharing that discrimination against Asian groups has increased since the COVID pandemic. Currently, Asian Americans are going through a period of collective racial trauma. Five million Asian Americans have experienced racism during the pandemic. If you would like to learn more about this nonprofit's mission, you can visit them online at stopaapihate.org. You can also submit a report on their website if you or someone you know has faced discrimination. Thank you. And just a little bit about what medical students have been trying to do within our communities. We have about seven to eight branches within the national branch of ours, and a lot of what we do is try to do community outreach, doing some of these health fairs. A thing that we're really proud of is launching our Anti-Asian Racism Toolkit, and we also have tried to launch mental health initiatives to try to help our fellow peer medical students and trainees and a lot of policy statements and joint statements with other organizations that kind of help us join solidarity, and then this month, AANHPI Heritage Month, a lot of events that we do mostly through virtual, and then for local and regional chapters, they can also do their own events as well at their schools. This is part of the Anti-Asian Racism Toolkit. So a couple years ago, we had like a day of action that we kind of dispersed this information throughout all of our chapters, but just wanted to show that at a medical student level, these are the institutional recommendations that we provided for our local chapters to send to their school administration. So some of them is publicly denouncing anti-Asian racism and violence, inclusion of this kind of curriculum to teach faculty and staff, providing accommodations, recognizing the unique challenges of NHOPI, like I mentioned before, and looking at transparency, disaggregated data, being able to increase AANHPI faculty. So a lot of that we try to kind of bundle up and send to our chapters so they can provide it for their own institutions. And then next, I would like to introduce Dr. Gupta to present on his part. Thank you, Donna. Thanks, everybody, for coming in so early this morning to listen to our presentation. So today I'm gonna talk about a study that we did as a group led by Dr. Deng and Dr. Alexander at Stanford. So I'm gonna present the findings and what was the reasoning to conduct this study. So basically, it was entitled as COVID-19's Impact on Discrimination and Racism Experienced by Asian Medical Trainees. Now, talking about the background, why we did the study. So as you all may know, that physicians experience very high degrees of burnout, depression, and suicide. And clinicians and medical trainees often experience a lot of macro and microaggression, not only from their patients, but also from their colleagues and from their other healthcare employees at workplaces. And Asian American clinicians, they are more likely to be exposed to vicarious trauma because of the kind of patient that they work with who feel more comfortable sharing the intricate details of their trauma with their clinicians. And during the pandemic, as we have been listening this morning, there has been a tremendous increase in racism, aggression, and xenophobia against Asians in this country. And therefore, one could hypothesize that the same kind of experiences are being subjected to Asian medical trainees as well during the pandemic. So we had a few hypotheses going for this study. We believed that there will be a statistically significant increase in anti-Asian discrimination towards Asian medical trainees during the pandemic as compared to the pre-pandemic period. And we had two primary hypotheses for this study, that there will be a significant difference in the discrimination experiences between various Asian medical trainee demographic groups based on the gender, based on the training status, based on their sexual orientation, et cetera, before and after the pandemic. And not only the Asian medical trainees are being subjected to discrimination experiences, these experiences are also causing negative impact on their lives since the pandemic has started. And then we had a bunch of secondary hypotheses that we were gonna test, which I wouldn't talk about today due to time constraints. So to test these hypotheses, we had few aims which were gonna be helpful in addressing the hypothesis. So one of the aims was to evaluate differences in the rates of anti-Asian discrimination in the Asian trainees before and after the pandemic started, and to compare their social demographic correlates of these discrimination experiences, and also to take a deep dive into the kind of discrimination experiences that are happening, like whether it is just harassment, or is it violence, or is it microaggressions, like those kinds of things. And also to compare the level of community and institutional support rendered to these trainees by their respective institutions. Now, how the study was done, it was a retrospective cross-sectional survey. It was web-based design, and we used consecutive sampling approach, and this was done one and a half years ago. And the survey remained open for four weeks, and we created a survey questionnaire in-house using Qualtrics, and it took only five minutes to complete to increase the participation and success of the study. And every week, we offered $50 gift cards to the participants to, again, to promote, to make sure that the study is successful in recruiting the participants. Our selection criteria were pretty broad. We included everybody who self-identified as Asian adult medical trainee, including students, residents, fellows in the US. But we did exclude those who were minors and those Asian trainees who were training outside the US. And then just a brief overview of what the study questionnaire basically assessed. So in addition to the demographic information, we assessed the different types of racism experiences a year before and since the pandemic started, and the setting in which the racism occurred, whether it was at workplace or whether it was in the community, whether it was on the streets or in the school, and the impact of the racism and any functional impairment that happened because of racism, and also how this impacted their training and whether it led to change in the behavior on the part of the individuals who were experiencing the racism, and what are their concerns about the future, whether they are worried about harassment at work and personal lives, and in their personal lives, and whether they are concerned about their friends and family's safety, and also if they were considering seeking mental health care or they were actively seeking mental health care because of the racism experiences, and what kind of institutional support they received during these incidents, and what kind of support they got from the family, from their community, and from their friends. And most of these responses were recorded on a five-point Likert scale and in the form of yes and no questions to make it easy for the participants to answer. Now coming to the results, so I'm gonna briefly tell you what we found. So we had one shot of 400 participants in this study who completed the questionnaire. As you can see on the left side, in the gender distribution, overwhelmingly female participants completed the questionnaire, and then there were 24% of males, and almost 15% of non-heterosexual individuals. Heterosexual individuals. And in terms of their sexual orientation distribution, there were 71% heterosexual individuals, and 15% non-heterosexual. And we had a significant number of non-binary individuals. And these distinctions were based on this ethnic distribution and the region distribution. Which I'm gonna talk in the next slides, are based on the US Census data. So coming to the training distribution, status distribution, most of the participants were medical students. And then we had a few number of residents, like 20% of them, and very few fellows as participating in the study. And in terms of training region distribution, so most of them belong to West. Which is expected, because that's where most of the Asian trainees are. And then we had significant representation from Northeast as well. And limited from South and Midwest. Which is in accordance with the AAMC data. And then in terms of ethnic distribution, most of the participants in the study belong to Southeast Asian region. And 22% from the East Asian region. And there were very, very few South Asian, and 7% of multiracial folks. And then around one third of the participants were not born in the US. Which is a big number. And now, in terms of further results, around 15% of the participants did not respond to some of the questions related to their demographic details and certain salient questions regarding their negative experiences because of that discrimination. There was a statistically significant increase in all types of discrimination experiences, be it microaggressions, harassment, threats, and violence in the participants since the pandemic started compared to before. And a greater proportion of participants suffered violence during the pandemic compared to before. And then again, a significant proportion of participants experienced functional impairment due to the violence after the pandemic. And around one third of participants endorsed that violence didn't impact their training. And then another 30%, almost 30% reported very little impact of the discrimination, anti-Asian discrimination on their study, on their education. However, around one third of the participants expressed a great deal or a lot of concern about their family becoming victims of violence and 28% expressed moderate concern. And almost 45% of participants endorsed changing their behavior, which means they started avoiding going out or walking alone on the streets and or they started carrying pepper sprays with them for their safety in response to this anti-Asian violence indicating the significant psychological impact of this violence incidents in their lives. And then around 17% of participants were either considering seeking or were seeking mental health care during the pandemic. Now, I do wanna share that this number is pretty high compared to the national average where as Dr. Alexander mentioned earlier, that the proportion of Asian medical students and Asian students in general seeking mental health care is very low. So, but this showed that they are more likely to seek mental health care in response to the negative experiences due to anti-Asian violence. Now, around 45% of participants reported that their training institutions response to dealing with anti-Asian violence was far short of their expectations. So they were not happy with their institution's response. And the significant proportion of participants endorsed receiving great deal of care support from their families and peers, but very few endorsed receiving support from their institutions, which was very unfortunate. Now, in terms of how we understand these results, it was a large sample survey spanning various regions in the US involving both medical students and doctors in training. And we had very high completion rate. Almost 85% of people who started the survey completed the survey. The limitations are recall bias because it asked the participants to talk about their racism incidents, which happened a year before the pandemic as well. And it was a cross-sectional design. So we didn't really have the opportunity to really pinpoint cause and effect relationship here. And a large proportion of participants were women, which is consistent with AAMC data, recent AAMC data, which is showing that the number of women enrolling in medical schools is rising rapidly. And around 30% of study participants identified as being non-heterosexual and others, which is a very big number as compared to a recent large survey, which found that only 6% of individuals graduating from allopathic medical schools in the US were a sexual minority. So which invokes the concept of intersectionality again here in this survey, because not only these students are Asian, which increased the risk of violence and discrimination, but also a lot of them were sexual minorities as well, which further increased the risk of discrimination and violence. And around 30% of participants were non-US born, which again is consistent with the nationally representative study, finding that around 29% of the healthcare workforce in this country is constituted by non-US born people. Now, we also noted a very significant increase in anti-Asian discrimination since the beginning of pandemic, which is a very worrisome finding and in line with what we were expecting. And a lot of participants endorsed being impacted by discrimination and experienced negative functional impairment in their lives. And also they had to make behavioral changes in response to that. But there was no clear impact, negative impact on their training, which I guess probably because a lot of training went virtual, so they were still able to continue with their education. And a lot of them received support from their families, but they also expressed concerns about their family's safety due to the discrimination, which probably was also impacting their psychological mental health. And unfortunately, their training institutions did not really match up to their expectations in terms of the support that they wanted. So thank you so much for listening to this talk. And I want to acknowledge the research team led by Dr. Alexander Deng for giving me this opportunity to be part of this study and two very wonderful students, Donna and Zaria, who is with us and all the study participants who honestly and duly completed the survey. Thank you so much. Good. Good. All right, thanks Rishabh. And next I'm going to present the survey study of impacts on AANHPI college students. So after that first project, we wanted to study a different population, which is the Asian undergraduate students in the country. So a little bit of background here. During the COVID pandemic, younger adults and racial ethnic minorities have reported disproportionately worse mental health, increased substance use, and elevated SI. Since the pandemic started, over 11,000 hate incidents were reported to stop AANHPIhate.org. So almost half occurred in the early stage of COVID in 2020 and a majority of those problems are reported as harassment. And almost one third of the parents were concerned about their child being a victim of those hate or discrimination in unsupervised spaces and on the way to school. Hate has a devastating impact on mental health. Among those people who reported, almost three quarters named discrimination against them as their greatest source of stress. And half of those people experiencing discrimination reported feeling sad, stressed, anxious, or depressed as a result. So the need for mental health care among college students has grown exponentially. Not only are more students needing care, but also there's high acuity during COVID. Among those students, Asian college students have not only had to deal with these stressors, but also cope with racial discrimination and attacks. So almost like this population got dual attacks. So in a college student of color survey, I think Dr. Alexander also shared this data before. The emphasis I want to point out is that only about a quarter of those students experienced, they had the lowest level of prevalence of mental health treatment and up to almost like a quarter experienced perceived mental health stigma, which could have contributed to the lowest prevalence of mental health treatment that they have thought. So the goals of the study is to investigate the mental health issues and the racial discrimination experienced by Asian college students during the pandemic. And also to illustrate areas to help Asian college students and hopefully more broadly, the Asian community as a whole. So we have specific aims to compare experiences of racism, mental stress, including anxiety and depression prior to and after the COVID-19 pandemic started and the settings in which they occurred. And also to determine the prevalence and the different forms of racism experienced by those students. And also to address how the rise in racial discrimination is currently affecting Asian college students' mental health in the United States. So the study was designed as a cross-sectional web-based survey. And we included data on demographics, mental health, using PHQ-9, GAT-7. And we had a specific question to ask mental substance use status. We also used the brief PEDQ community version to assess the perceived ethnic discrimination. And we had questions to look at civic engagement and also access to mental health services. So based on the previous study, the first project we did, we set a target to get participants of 1,000. Within a few weeks, I think over the three, four weeks time, we were able to get a significant amount of responses. So eventually we included 1,006 respondents' responses to our final data analysis. So here I have some demographics data to show you first. So on the left, you can see the gender identity. Most of the respondents, majority of them are cisgender women followed by cisgender men. And on the right side, you can see the numbers for the sexual orientation among our participants. So mostly majority were straight followed by bisexual. And then the ethnicity, so as majority of those people, respondents are East Asian followed by Southeastern Asian and Southern Asian. In terms of the native language, most of our respondents filled out to other languages followed by Mandarin, Vietnamese, and other Indian dialects. Here I also have a pie graph on the native language. It's kind of hard to read, that's why I have the table on the right side to show you the specific numbers. And on the left side of this slide, you can see the university region. The majority of the respondents are located in the East Coast and the West Coast. Also consistent with our first project's results. And the undergraduate year, majority of them are first year followed by second, third, fourth, fifth, fifth year or more in that order. So here I have one slide to show you some preliminary findings. We recently started the data analysis. So some of the preliminary findings include, we did find a significant positive association between how much respondents relate their anxiety symptoms to COVID and or race and ethnicity background. So we did include a few of the demographics variables into our analysis. Gender and sexual orientation turned out to be significant covariates. We did not find a significant association of the respondents' PHQ-9, basically the depression symptoms to COVID and or race and ethnicity background. And also we did not find a strong correlations between PHQ-9, GAT7 and PDQ-CB. So those are just the preliminary findings. Hopefully next step, we're going to look into the other aspects of the study. So I just want to thank the grants we have received to support those two projects. We did receive three grants supported from Stanford Care Center Grant Award and also the Stanford Psychiatry Department Innovative Grants for two years support. And also we want to thank the Stanford BERT Institution to support our statistic analysis. And last but not least, I want to thank our team of trainees. So Zaria is among the audience today and Rishabh started the project with us as a fellow, now working as an attendee. And Donna here was presenting today. So I have a picture of Mara who's on the East Coast at Cornell University. So just to name a few of them, but thanks to our wonderful team. I'll hand over to our next session, small group work. You guys can come to the front. Or just, yeah. Okay, so thank you so much, Dr. Gupta and thank you, Dr. Deng. We really appreciate all your work on these studies as well as our research team. We're going to transition to some small group work. So we would like you to pair off with, and we might need a group of three somewhere. If you would just take a minute to introduce yourself, let them know what you do, where you're from, if you're in training. And then, oh, I'm sorry. We have to watch this video first because that's what our first case is based on. So let's watch this and then we will break out. There are some new developments in the racist and homophobic harassment that happened Christmas Eve at a San Ramon In-N-Out. John's boyfriend. You're Kim Jong-Un's boyfriend? That's some bullshit. Anyway, if you can try the fries. Elliot Ha and Irene Kim were making a food review video when a man just started insulting and then threatening them. Now, San Ramon police say they've arrested the suspect for violating California hate crime laws. Betty, you talk to the victims tonight. Irene Kim and Elliot Ha came back to this same In-N-Out on Monday for burgers and fries and they said they felt safe eating here. I spoke with them shortly after they gave their statements to the San Ramon police department. Don't let it get spit in your face. That's a Filipino piece of shit. That's a Filipino piece of shit. Why would he do that? Dude, we can get assaulted. In a three-minute TikTok that now has more than 10 million views, Irene Kim and Elliot Ha capture racist and homophobic rants from a man who approached them while they were filming themselves eating items off the secret menu at In-N-Out. Anyways, you can try the fries. In less than 48 hours, San Ramon police announced that they've arrested 40-year-old Jordan Douglas Craw of Denver, Colorado. He's been charged with two counts of committing a hate crime. A lot of people were commenting originally, like, why didn't you call the police in that moment? And I think for us, like, especially for a lot of people of color, a lot of Asian Americans that go through hate crimes, like, I've been verbally assaulted on more than one occasion, not to the degree that that man went to, but, you know, like, you, most of the time, you don't think that someone will ever really take you seriously. And when we were talking to the police earlier today, one thing that they mentioned that kind of stuck with me is nothing is too small to be reported because they would rather be glad to get the call and figure out that it really is nothing rather than have it actually be something. Irene said someone recognizes sus... Oh, sorry. There are some new developments in the racist and homophobic... Okay, and I cut off... There are some new developments in the racist and homophobic... Okay, sorry about that. So, and what I cut off at the very end is actually someone saw a picture of the guy and reported him in, so that was very helpful to have somebody do that. And just to reiterate, because I know it might've been a little hard to hear, but this happened right here in the Bay Area, and the two victims are students, and you probably couldn't hear all the insults. There was a little line, some subtitles, but they might've been a little hard to see exactly what he was saying, but it was pretty bad if you could see it. So here's our first case. So you are treating an undergrad student for depression and anxiety for the past six months. Similar to the video, one day they had a similar experience where they were the recipient of an angry, verbally threatening, anti-Asian confrontation by a stranger that they didn't know in a public area. And since this happened, they feel scared, they have trouble sleeping at night, and find it hard to concentrate on their schoolwork. So some questions to think about. What are your treatment considerations at this point? Like, do you do anything differently clinically? How would you address and approach a discussion of this racist incident with this student? And if the student asks how to get more support after experiencing anti-Asian violence, what would you suggest? Again, this is an undergrad student. And if the student asks for your advice on what to do next, stating, I don't want this to happen to other people, what can I do, how can I help? What would you suggest? So if you could take just two minutes to talk with your neighbor and introduce yourself, and then we will try to hear from everybody about what they have discussed. Okay, so we will wrap it up and bring it to the large group so we can kind of share some of these ideas. There's not necessarily right or wrong answers here, but we do want to hear people's ideas. And so what about the first question? So what are your treatment considerations at this point? You can raise your hand. Rishabh or Donna will bring the microphone to you. Yeah, great. Okay. I think this is a young student that already was being treated with anxiety and depression. And as we discussed in our group here, this incident, the racial discrimination, only serves as an additional stressor. and not only that particular incident, but also watching on the news of other people that have been affected, that I think magnifies the degree of that stressor for that individual. And I think we need to keep that in mind, that our one trauma results in having a compounding effect, even if it's a small thing, but it gets magnified because it makes you remember all the other things that you have heard, oh my god. And then how that impact on the individual's existing anxiety and depression, one of the factors of social determinants about the symptoms and mental illness is one of these factors, and those should be addressed in therapy. Would you evaluate them for PTSD with the diagnostic criteria? I don't have the diagnosis before. Well, I mean, when you say you evaluate them for PTSD, which means I'm starting with the premise that they have PTSD. Not everybody that has trauma has PTSD, including war veterans, including victims of violence during wars, you know, that was in a famous study in Serbia, that they showed that you don't necessarily get PTSD, but that doesn't mean that they are not impacted. There may be other symptoms of anxiety, depression, sleeplessness. Those are equally important. I think we don't want to get hung up that if they don't have PTSD, it means they are not affected. So I would certainly keep my options open and see where the student leads me to in terms of the diagnosis. Instead of making up the diagnosis and then seeing if they meet the criteria of DSM, then I'm kind of shutting the door and I'm not listening to the individual in front of me. Yeah, wonderful. Thank you. And I think what you're referring to there is, yeah, it can be described as vicarious trauma if you didn't, I mean, in this case, this person experienced it directly, so not as relevant unless they are also seeing other videos, right, but it's the trauma that people can experience just watching these incidents and graphic incidents of what has happened to other people. So and then how would you address and approach the discussion of this racist incident with the student? You could imagine there's a wide range of responses from a student maybe mentioning it and not really wanting to talk about it, to someone who really does want to talk about it and process it, to someone who maybe you didn't even know this happened, like maybe they have not even brought up that this happened, right, but they're having worsening symptoms. So I think we all talked about validation and allyship, but also curiosity and exploration. What does this mean to the student and, you know, this is often the tip of the iceberg of what they've experienced and how has this impacted their identity, their sense of safety and sense of connection with others and self-concept as an Asian-American student. Wonderful. Thank you. Definitely. And it may bring up past trauma, you know, have there been similar incidents that they've experienced in the past? So a lot to explore there. What if they are wanting more support after experiencing this? Anybody come up with ideas about this? One of the things that we discussed here in our group, and one of our group members suggested having them join the Asian clubs at the school, and I think where they feel safe in talking about it, and they feel that they are not alone in this, and that really helps draw these people out to talk about it. And then also one of the suggestions I had was, you know, help them, point them in the direction of various organizations that do this kind of advocacy work and volunteer there and associate with them, that will kind of help empower them more. Definitely. And you also mentioned active allyship to the other group in the back, so absolutely great ideas. And number four, thoughts about this. So I don't want this to happen to others. What can I do? I'll give a hint. This came up earlier in the presentation. Oh, what? Yes? Hey there. I know that we had a nice discussion about all the different action steps that can be taken and then really supporting that person to feel empowered, and the idea of being able to move beyond the traumatic event to be able to be helping others and collectively, so stop API hate, reporting it, reporting it through the school and educational structure that the student is within, whether or not there's any additional support, as well as, you know, obviously they're in treatment, so thinking about the perspective of therapeutic skills, but also just thinking about how have they been dealing with some of these things before? So what skills, what coping strategies, what other things might be helpful for them? But taking action would be really powerful. »» Wonderful. Thank you, Dr. Ng. I'm just going to put you on the spot. Dr. Warren Ng is the President of ACAP and we're very pleased to have you join us today. So case number two. So you are the attending on an inpatient psychiatry unit. Your team is conducting a group interview of a patient and the patient starts to focus on the Asian trainee who is asking them questions and makes derogatory racist remarks to them. So number one, what do you do? Number two, do you stop the interview? Why or why not? Number three, do you report what happened? And what are the guidelines and procedures at your facility for these sorts of situations? Who do you even report it to? How do you support this trainee and how would you follow up with them, if at all? And then another question, how do you continue to provide quality care to this patient? So take a couple minutes and talk amongst yourselves and we will get some thoughts on this situation. Okay. So I think we're going to bring it back. It's okay if you didn't get to all the questions, but we would like to get some thoughts. So how about the just first overall question? So what do you do? How do you, you're the attending and want to mention during COVID, there's definitely been, you know, isolated incidences of pretty serious attacks, verbal harassment on Asian physicians, Asian trainees, Asian medical students. So yeah. Thank you. Hi. Hi. Yeah. So if you Google, can I withhold care from a bigot, two articles will come up. One of them is a New York Times column by Kwame Anthony Appiah and one is my response. It should come up. So basically this is an ethical question. It's a safety consideration for the lowest person in the power relationships going on here. That's right. Yeah. So it's all about support of the patient, but also you're ethically bound to care for the patient. Okay. But this is a treatment splitting point. So if the trainee doesn't get support, they will be split in some way. So but I think the ethicist suggested of course that the patient's medical and psychiatric conditions may be producing, amplifying whatever is going on. So obviously we're bound to care for the patient. Now what if there's another member, I mean, it's an attending, it's a team structure. So maybe this trainee doesn't have to be involved in this patient's care. There's other doctors who can do it. But they're still impacted. And this should be a point to build the team, I think. Thank you. Thank you. All right. And then how about do you stop the interview? Do you report what happened? What about your facility? I have a question. Sure. So you mentioned that a trainee doesn't have to be to provide the care to that patient. That may not be the best thing to do. That may encourage the patient that, yes, I don't want. This happens actually in the hospital every day. Patient will say, I don't want this doctor. I don't like him or I don't like her. That's right. So maybe we should insist that this is not appropriate. And if you do this, we cannot help you here. And we appoint this trainee or this doctor for you. And you cannot pick and choose. That's right. No, that's a great comment. Because it could be very enabling, right, if this time they didn't want to work with this doctor. And then now they know that if they say something like that, they don't have to work with an Asian doctor. So absolutely. And a similar case came up. And there were different thoughts about handling it. There are interesting comments, including understanding the laws. And in some states now, I think in Florida, you don't have to treat a patient. This is getting tricky ethically, but apparently you don't have to if you don't agree with them or agree with the way they're treating you. I do like more what you said about institutional policy. And I know at Stanford, we've seen more attention paid to harassment of health care workers, especially during COVID, but also racially. And so that's right. There are now signs put up everywhere that that type of behavior is not acceptable. And it might affect, right, whether or not we can offer care or not. But you're right not to split out the Asian person that's being harassed in a situation like this. Other final thoughts about this situation? Yes. Thanks. I think that creating, I think it's really important to, particularly when it's happening in the clinical setting, to be able to frame it around safety. Because I think one of the things that's really important is for the individual who's making those comments, also to let them know that setting some limits, even if you're doing a diagnostic evaluation, you can still say that you're creating a space where we can all provide the care that you need, but without hurting and or sort of disrespecting other people. And so I think that being able to set some of those, and then also the vicarious trauma, because I think even if we're not identifying with that particular identity, we are all experiencing really discriminatory behavior. So there are also the clear guidelines for trainees within training programs that creates sort of the optimal learning environment for cultural sensitivity. So I think that those are other, as well as your institutional guidelines as well. But yeah. So thanks. Absolutely. Yes. And it can be very powerful for the attending to not like ignore what happened, right? But to address it with the patient and be able to explain that this is not acceptable behavior, or this is not going to be tolerated, and also to check in with the trainee afterwards to see what their needs are. And again, I think trainees' responses to situations like this can also be very variable from some who don't really want to talk about it much, especially with people they work with, to trainees that do want you to say something or do something that's more proactive so that they don't encounter a situation like this again. Okay. A little brief on time. So I'm just going to go through a couple other slides that we have. So kind of to sum up sort of the allyship component of this, we like to bring this up because we do think there needs to be community societal change, too. So in academia, if you work on a campus or work with students and work in an academic setting to support the Asian and minority student-led campaigns on your campus, to support education against discrimination, including bystander and upstander training, support the hiring of educators and staff of color, and make sure your institution responds to anti-Asian racism events that happen nationally and internationally, because that can really affect students as well. Be conscious of the minority tax. Maybe that needs to be on our list of terms, too, so people know. But basically, this is educating your department about the need for non-Asian allies to lead and address efforts against anti-Asian racism. So it's not just falling on Asian people in the department. Active allyship, like we mentioned, so the commitment to organizing, mobilizing, and empowerment, and learn strategies to address anti-Asian racism in our communities. Oh, I forgot to put one here. One is to vote, because politically there's a lot going on right now. And we didn't talk about this too much, but, for example, I have a colleague in Florida who cannot really even give DEI presentations like this anymore. And I feel fortunate to be in California, because we don't have loss of that freedom. But be an upstander and learn what that means and how to do that. Support anti-bullying training, especially for youth, because so many of these attitudes and violent attitudes and violence towards others and hostility towards others starts young. To support rallies and marches in your community and help communities apply social pressure against hate. We put this sign here. I don't know how many people have seen this yard sign in your community. Yeah, so I think it's not all over the country, but like in our neighborhoods there's some neighbors that will put up a sign like that. And it's great to know, even if I don't know those neighbors personally, it's nice to know that there's people who feel this way. And so to take a stand. We just met in the Asian Caucus, and they are putting together a 5K more equity mental health initiative. And so we are trying to get participants. And you can see there's different MUR caucuses. We are the Asian Caucus on the far left. And we would like to get as many participants as possible. You don't necessarily have to pay anything, but just join. And it's an opportunity to raise awareness about the disparities in mental health for youth of color. If you do decide to donate, the money will go to community grants program that focuses on promoting mental health for youth of color. It's free to register and join your caucus team. So we would like everybody to do that. And not only do that, but encourage a couple other colleagues to as well. Okay. Donna. Just a few more slides wrapping up here. I feel like I'm preaching to the choir. If you did not know, this May is AANHPI heritage month, like I mentioned before. If you're at an institution or if you work with students, which I think everyone here is interested in doing so, there are a lot of not only undergraduate AANHPI groups, but there's also like the Asian Pacific American Medical Student Association, like I mentioned before, if you work with medical trainees. May is also mental health awareness month as well. So if you check out SAMHSAs or NIH or NIMHs, social media handles, they've been doing a lot of blast, especially on youth mental health as well and suicide prevention. And then lastly, we even have our own day. I didn't even know that. It's Wednesday, May 10th, which passed a little bit. It's okay. I was a little scared of that. But it was actually AANHPI mental health day. So that was really empowering seeing a lot of the social media platforms be able to blast that out and try to get some attention to that. And just wanted to give a little shout out to our team. Last year, I was fortunate to be able to intern with the US Senate help committee, which is then headed by Senator Patty Murray and now headed by Senator Bernie Sanders, but basically met with the White House initiative executive director, Chris Okai, who heads up that for the Biden administration and really wanted to push for more psychiatry involvement since they are trying to give recommendations to the Biden administration to do a mental health summit, to push out a youth mental health campaign, to expand fellowships, repayment programs for AANHPI, behavioral health professionals, et cetera. But, you know, we are small yet mighty. So really trying to push out, you know, having psychiatrists on those initiatives, on those boards, giving these recommendations. And you can see Dr. Alexander was there and Dr. Warren back there was there as well. But, yeah, they pretty much used all of our recommendations, which was very inspiring. And they also even had like a mental health summit day. I think it was like May 3rd or something. But there was an actual mental health breakout session convening that happened. And, you know, I like to think that we all kind of pushed that needle forward. So it was really inspiring to see Kevin Kreider was there, too, from Empire Bling, if anyone watches that. No? Maybe? Okay. Well, it's on Netflix. Yeah, you'll see it. Yep. And then just to show, you know, I especially am very happy that SAMHSA, for example, has a page like this that shows about behavioral health equity resources, a lot of like different reports, issue briefs. There is, you know, currently a push for a national survey for NHOPI, since like I mentioned before, SAMHSA doesn't even have those numbers. So they're currently asterisk, not even a zero. There's not even numbers there. And then just showing about federal initiatives and resources, about agency for healthcare research, there's some on healthy minds, and just external resources in general. A lot of these you may have heard about before. And NIMDH has wonderful, wonderful webinars. I know you all have plenty of time to watch these, but if you have, you know, any during the day, you just want to listen when you're, you know, bathing or whatnot, then, you know, this would be great to just kind of listen to. Anything? Okay. And I'll let Dr. Alexander close us out. Well, we thank everyone for your involvement and participation today, and hope that you have learned something that we've, and it was great to think through some of these tough issues with you. So thank you very much. Thank you.

Anti-Asian racism

COVID-19 pandemic

Asian college students

Asian medical trainees

mental health

racial trauma

cultural competence

allyship

community involvement

Stop AAPI Hate

systemic change