Thank you for joining today's webinar. To kick things off, I would like to introduce our moderator to begin the introduction of this session. Hi, everyone. I am glad that you were able to join us today and listen to Dr. Hurston and her wonderful presentation. We have a few things to go over before she jumps in and engages us to a tea. These are some funding and disclaimer in terms of how this webinar series, which is a series of different talks, is funded, which is funded through SAMHSA in partnership with APA and the African American Behavioral Health Center of Excellence at Morehouse University or School of Medicine. For those of you that are interested, there is one CME credit available and more information about that will be provided to you at the end. Here is some other useful information in terms of how to download handouts that are attached to this presentation and even how to figure out some of the buttons that are on the right-hand side of you. There will be a Q&A at the end of this talk, so if you have any questions, please feel free to add them in and we'll get them in at the end of the presentation. Without further ado, I want to introduce Dr. Danielle Hurston, who is a double board certified adult consultation liaison, psychiatrist, medical educator, author, speaker, and promoter of mental wellness. She was raised in Washington, D.C. She attended Rutgers University for her undergrad education and earned a degree in biological sciences. She went on to earn a medical degree at Howard University College of Medicine, where she was the chief resident for the Department of Psychiatry at Howard University Hospital, where she completed her general psychiatry residency. She completed her consultation liaison psychiatry fellowship and went on to become faculty at the University of Maryland School of Medicine Department of Psychiatry. In 2018, Dr. Hurston returned to Howard University College of Medicine as an assistant professor and was recently appointed as the psychiatry residency program director. Currently, she serves as the APA Black Caucus president, where she has served as the Black Psychiatrist of America scientific program chair since 2016. She has spoken nationally and internationally about the impact of race and culture on mental health, and she is a contributing author to a recently published book, Racism and Psychiatry Contemporary Issues and Interventions. Her interests include consultation liaison psychiatry, resident education, underrepresented minorities in medicine, faith and mental health, and health and racism. And so without further ado, I would love to introduce you to Dr. Hurston, who is going to just grace us with her knowledge and the information that she's going to provide here today in her presentations. And I do want to add that she has no financial disclosures to report. Thank you, Dr. Denny, for that introduction, and thank you to APA, and thank you to Morehouse for inviting me. Shout out to Dr. Sarah Vincent, and thank you to Ebony Harris for getting us all the way together for this presentation. So I have a lot of slides if you look into the handouts, but I will not be going through them completely, but I will try to give you the pertinent facts and information. This is something I usually do in about three to four hours. So I'm looking forward to the participation and questions, and these are the goals for the workshop. Obviously, the title is from Draftomania to Schizophrenia. There's a lot in between, but we will try to really understand the impact of racism on Black lives and mental health. We will identify examples of systemic racism in healthcare and how they contribute to inequalities, and also discuss strategies to reduce bias and racism in psychiatry, including within patient interactions. Now, these are just potential solutions. These are not the only solutions. These are not the only steps. And also, I want us to be clear that these are not only things that are up to psychiatrists. These are not things that are only up to the Black community. These are things that everyone needs to work on in a collaborative manner. So first, we're going to get into some definitions, and I really want us to open up by understanding that all racism is not overt. A lot of times we hear people say, well, I'm not racist. I know I don't believe in lynching. I know that the Ku Klux Klan is not appropriate. I know that you shouldn't discriminate against people on a one-to-one basis. That's not what we're talking about when we're talking about systemic or institutional or structural racism. So there are levels to this. What I describe and what most people think about is interpersonal racism. And then one that many are not aware of is internalized racism. So we're going to talk about systemic racism, but I want you to be aware of all the definitions. You will hear me use interchangeably systemic, institutional, and structural racism. So let's make sure that we understand what systemic racism is. I was on the APA's task force for against structural racism, and this is the definition that I think is the most appropriate. It's from the Aspen Institute, which I recommend that you look into their definitions. They have 11 terms that everyone should know, specifically psychiatrists, but everyone in this country should be aware of who are treating patients who are just living in this country. So systemic racism is a system in which public policies, so policies, institutional practices, that's why we say sometimes institutional racism, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity. So that's when structures are in place, systems uphold norms that continue to perpetuate racism. It identifies dimensions of our history and culture that have allowed privileges associated with whiteness and disadvantages associated with color to endure and adapt over time. So that's what we mean when we say systemic racism. I think this is sometimes hard for people to swallow, hard for people to understand. So we're going to go through some examples now. So you hear people say, I'm not racist because they don't truly understand how we live in a system, a country that has been embedded with systemic racism, which it is a part of every fiber of every policy of every practice in this country, including education, including housing and including medicine and specifically psychiatry. But when we talk about systemic racism or structural racism or institutional racism, we really need to be aware that racism can be explicit, but that is just one manifestation. Sometimes it is something that's deeply embedded that you might not even recognize or be aware of. But if you are continuing to practice and care for people in this country, you need to be aware of these things. One example is denying that racism exists in any facet, in any realm, in any environment. When an oppressed people say something is going on, they're reporting something and you say, oh, are you sure that that was racist? Or I don't think that was racist. That is an example of something called gaslighting, which we should be well aware of here in psychiatry. Also things systemically, structurally, really, if you think about what is the greatest way to achieve wealth and success in this country, it's by home ownership. When you deny home loans to Black people from certain neighborhoods, limiting their potential for building economic wealth, a policy that was put in place by the federal government back in the 1920s and 30s, this is called redlining. That is how a system perpetuates practices that are discriminatory against people of a certain race. Weaponizing privilege, we have all heard of calling the police to report Black people for eating, sleeping, sitting, birdwatching, jogging, barbecuing, any of those things. This is an example of racism that can be perpetuated by cultural norms. Other examples, when we think about a system, is the legal or the carceral system, where there are sentencing disparities, which are sentencing differences between offenses for crack and powder cocaine, because crack cocaine is thought to be the substance preferred by Black and African-Americans. Spoiler alert, actually, White people use crack cocaine at an even higher rate than Black people. Other things that we can see institutionally are refusing to hire and promote Black employees, using coded language like, they aren't the right fit, or things like that, when truly the feelings are about a person's race or their appearance. Then one we should definitely be aware of is providing biased care, treating BIPOC patients and White patients with the exact same symptoms and concerns differently. This is something that we really have to understand, because it's something that continues to happen in psychiatry, which has been happening for years, for hundreds of years. It's been documented since the 70s in earlier research, but it's something that continues to happen right now. I'm not going to go too far into this, but just know that personally mediated or interpersonal racism is what we think of when we say, what most people think of when they think of the term or word racism. That can be intentional, it can be unintentional, it can include acts of commission and acts of omission. It maintains structural barriers, and it's condoned by societal norms. This is something that you should really look into the levels of racism by Dr. Kamara Jones. Examples of interpersonal racism are a lack of respect, suspicion, devaluation, scapegoating, de- and dehumanization. If you go back to these handouts at the end of the presentation, you will see examples of this. These are things that are like one-on-one police brutality, sterilization in Black communities for medicine, hate crimes, and things like that. These are one-on-one interpersonal racism examples, but they are supported and allowed to endure because of the system and the cultural norms that support these feelings and these actions. What is a bias? A bias is a preference that may be favorable or unfavorable. A racial bias is a preference towards or against a certain racial group. Explicit bias, explicit racial bias, this is one that people are able to really understand. They say they don't really have a problem with understanding this. A clinician or physician acknowledges that they have a preference or an aversion to a certain racial group. It can be suppressed or acted upon due to societal norms, due to institutional practices, and due to structures that are in place. It can't lead to racist acts that are purposeful. These are things that are obvious that people can identify as incorrect or as offensive or discriminatory, like a physician who refuses to provide care for Black or Latinx patients, a physician who joins an anti-immigrant rally protesting clinical care for Latinx immigrants, things like that that people can easily identify. Those are things that we would describe as being on the top of the iceberg. Now implicit racial bias, these are unconscious associations of stereotypical attributes with particular racial groups. These are things that most people hear and experience. Similar to explicit bias, they can manifest as preference or negative association. Typically you see these in a stressful or high emotional tone situation, fast-paced and toned situations that can lead to expression of behaviors consistent with implicit bias. Quick example of implicit bias and how this works and how the culture, the norms, and society can perpetuate these things. People say there's a physician whose neighbor was robbed by an African-American male a few days prior, earlier in the week, and is currently working on an active inpatient unit. The physician watches the nightly news where African-American males are often profiled as aggressive or violent or dangerous. During the shift, an acutely agitated African-American male is having a psychiatric crisis. The patient who was initially posturing and threatening becomes calm and the situation is de-escalated after staff approach. The physician now, who has this implicit bias because of the culture, because of things that are perpetuated, feels threatened and unconsciously insists that the patient should be restrained to manage potential aggression even though the patient is no longer aggressive. The patient is started on a high-dose antipsychotic despite the patient's calm state and lack of consensus among the staff. This would be an example of how an implicit bias that is supported by cultural norms that you see in the media, that you see in your families, that you see culturally can lead to higher doses of antipsychotics with African-American men because of her experience that they can be very aggressive. This is something that is taught to students and residents and perpetuated in the institution in the structures. That is how we connect this to structural or systemic racism. How has history influenced these structures? You're like, okay, Dr. Hairston, you're talking about bias, you're talking about structural and systemic racism, you also talk a lot about history. How are they all connected? If you look at this, structural racism feeds into clinician bias, which feeds into structural bias, which is back connected to racism. It's a continuous and unfortunate cycle, and if we don't do anything to step in and find solutions, it will continue to be potentiated. Now I'm not a historian, I do definitely enjoy learning about the history in this country because I believe in Sankofa that if you do not understand where you came from, you cannot understand what's going on with you now. Just some examples, some notes here for you to take note of and understand how scientific racism has been used to justify colonialism and slavery. We can go all the way back to Linnaeus' work in 1735, where he was the first to create a classification of race based on skin color, and then he assigned these different attributes to people because of their skin color. He had two groups, homo europeus, and that was a fair complexion, nice calm temperament, gentle manners, acute in judgment, governed by fixed laws. And then there was a homo afer, which was a black complexion, crafty, indolent, indolent, being lazy, not wanting to do work, and governed their actions by caprice, which means unaccountable mood swings that you can't really understand. So that's something that happened even back in 1735. We move closer to what we see even now in 2000s with the UVA study a couple years ago that many of you are aware of, if you're not, please look that up, that physicians and medical students said that they believed that black people have higher pain tolerance and black people have different nerve endings, and so that they do not require the same amount of pain management and medications because of this. And this is something that we see going back years ago to Christoph Meiners, who claimed that the Negro had thick nerves that could tolerate more pain than any other race and lacked emotions and sensitivity. And I'll speak more into this lacking of emotions and sensitivity and how it really contributes to the stigma that we see today and the difficulty that we see in clinical interactions, and that also the Negro can partake in the most and worst indigestible foods. So here we have another example in history of Benjamin Rush. I don't know if many of you recognize him, but Benjamin Rush is called the father of American psychiatry. Up until a couple of years ago, even when I was a resident, Benjamin Rush's picture was part of the logo or the emblem for the APA, which now looks a little different, but we still have here at the APA an award named after him. He was a signer of the Declaration of Independence. He was the father of American psychiatry, and he also happened to come up with this term diagnosis called negritude, and he said that having black skin was a mild form of leprosy that could only be cured by becoming white. He owned a slave or an enslaved man named William Grubber. He actually didn't speak about William Grubber or mention William Grubber at all until he freed him, and he did make it known that he paid for his hospital bills and he paid for his funeral after William Grubber passed away. However, many people are not aware that Benjamin Rush, I'm sorry, the father of American psychiatry, also happened to be a slave owner, and this is why this could be offensive in this American Psychiatric Association as we continue to honor this man and have an award for him. What we see throughout history is a pathologization of black liberation. Samuel Cartwright, who was a prominent Louisiana physician, he was not a psychiatrist, but he was a prominent Louisiana physician and a leader in the pro-slavery movement. Rush is also known to have provided a medical apprenticeship to Samuel Cartwright, who came up with the term Draftamania. So the title of my presentation is From Draftamania to Schizophrenia. So Draftamania was a disease, a disease coined by Samuel Cartwright, which was only seen in Black formerly enslaved people. It's not seen in slavery, but seen in formerly, I'm sorry, it was seen in slavery with people who were enslaved, who wanted freedom, who wanted to run away, and who were going against the grain and wanted to be free and escape. Wanting to run away, wanting to be free, wanting to be liberated, that had to be a mental illness. Something had to be wrong with them, and the treatment simply, per Cartwright, was whipping them and continuing to beat them. In the 1840 U.S. census, it claimed that enslaved Blacks were free of mental illness. So before, while they were enslaved, they were free of mental illness, they didn't have any issues, but once the Black man becomes free, they become prey to mental disturbances, and it all comes when they become free and are able to actually be liberated and control their lives. In the further north, the more insane, and these were, that was in 1840, and Samuel Cartwright was around the same time, and you might think, okay, Dr. Harrison, that was in the past. When I did the New York Times interview and article, I was told, I got a lot of feedback on Twitter and social media that, oh, well, why do we have to apologize for things that our ancestors and our great-grandfathers did, and why are we still talking about these things? So first of all, this wasn't that long ago. Second of all, no one is saying that these need to be apologized for, but what we do need to do is understand how these structures and these systems continue to persist, and how we go from drapsomania, where Black people who wanted to be free were seen as mentally ill and psychotic, now to schizophrenia, which has become a disease of the Black man, the aggressive, angry Black man, and how systems and cultural norms continue to perpetuate these things. All right, so this is an example of, so I'm here in DC, the DMV area. This is Crownsville State Hospital, formerly known as the Hospital for the Negro Insane, which was in full practice and functioning from 1911 to 2004, so that was not too long ago. 2004, I happen to still be, I happen to have just graduated from high school, so this is something that was in place. Now, you did not have to have, early in the 1900s, you actually didn't have to have a documented mental illness to be admitted to this hospital, and many state hospitals for the Negro Insane across this country, the South, the South predominantly, but also in the North as well. It could be that you were seen as disrespectful. You wanted to become educated. You wanted to go to school. You wanted to register for college. Those were all reasons that you could be deemed, and it was determined that you could be insane and be admitted to these state hospitals. So, American colonization and slavery really put in place a system and a structure in which Black people and slave people had a couple options. You could do one of two things. You could submit, or you could die. You would be punished for being defiant, mature, or independent. You were punished for having the traits of high self-esteem, self-love, self-value. These were incompatible with survival, and presently, we see the effects of these things clinically and broadly in society. So, we see in treatment settings, patients who may suppress or deny anger or their emotions or what they're going through because they know that they have relatives and people that they are aware of who were admitted to insane asylums, who were deemed to be insane because of the history and things that are passed down. These denials become normative, and what is acceptable is withdrawal or inward self-destruction, and also, this perpetuates stigma in Black and other BIPOC communities because you don't talk about what's going on in your home. You don't talk about what's happening in the streets. So, again, how has history influenced these structures, and if you're coming along with me, I hope that you're understanding and seeing that as racism persists, as we go through things in our, as we go through things in society, psychiatry and medicine have gone right along with them. So, a couple cases that I'm going to tell you, the biases in medicine that have been perpetuated because of things that we saw back in the 1700s, the 1800s, the early 1900s. Now, biases in medicine are not only in psychiatry, so I don't want to say that these are things that we only see here, so a couple, three important cases for you to know about. I already told you about the Hoffman et al in 2016 at UVA with the pain ratings. You should also be aware of a very important case, Schulman 1999 for cardiac catheterizations. Physicians were asked to characterize the type of chest pain described by a patient and what was the next best step in treatment. The only thing that was changed for these patients were the patient's age, race, I'm sorry, were the patient's race and sex. Age was the same. Same description, and physicians were asked if they wished to order further cardiac evaluations for the patient, and they were given four options. You could do no stress test, a regular stress test, a stress test with thallium, or other functional cardiac assessment. They were the exact same clinical pictures, and what we saw across the board back in 1999 was physicians were that men and whites were more likely to be referred than black women, especially for these cardiac issues, even though they presented with the exact same symptoms. If you think that's, like I said, it's not just in psychiatry, but we do have the same thing here happening in psychiatry. In 1988, there was a study with 290 psychiatrists. They were given standardized case descriptions, which varied only by patient's race. Case descriptions of African-American patients were more likely to be diagnosed with schizophrenia rather than a mood- or stress-related disorder. The exact same case descriptions, the exact same case descriptions were given to psychiatrists, and black people were still more likely to be diagnosed with schizophrenia rather than a mood- or a PTSD-like disorder. If you think, okay, Dr. Harrison, that was, those were in the 90s. Those were in the 80s. It continues now. Straussky, this is the 2003 study, but Straussky also has a 2017 study, which was definitely not too long ago, and in the 2003 study, 79 patients with an expert consensus diagnosis of affective disorder were presented to psychiatrists. The death, the diagnosis should have been an affective disorder, but they had one psychotic symptom. African-American men in this study were significantly more likely to be clinically misdiagnosed with schizophrenia or a psychotic spectrum disorder in comparison to white men at a rate of 47% versus 16%, even though we're giving you the exact same, exact same clinical picture. So, where do we see clinical bias and racism lead to misdiagnosis and inappropriate treatment? Where does this happen in psychiatry? It happens everywhere. It happens during the development of the working alliance. If a clinician or physician, psychiatrist, whoever it is, exhibits a nonverbal communication of hope or despair or mistrust or skepticism, a patient feels this, and the clinician interacts in an overly familiar manner with a patient or alternatively lacks interest in details of the patient's story. An overly familiar manner would be something that you can see like, oh, well, all Black patients do this. All Black patients use substances. I expect their urine drug screen to be positive. I've seen patients like this so many times before without actually understanding who the patient is as an individual. It can happen during the diagnostic assessment, which I just went over there with you, a couple studies for schizophrenia, but there are other examples as well, in which the clinical diagnosis is impressionistic rather than based on a thorough diagnostic interview with strict adherence to criteria. Questions to elicit core symptoms may not be asked, and this is something that we see with Black patients and Latinx patients and other BIPOC patients time and time again. Another study has told us that the process of arriving at a mental health diagnosis is subject to bias. DSM-5 or whichever DSM it is at that time are not always, the criteria are not always systemically applied, and race and ethnicity can impact the diagnosis through inadequate screening and through greater emphasis being placed by the clinician on reported symptoms without digging further. So, I know the title of my presentation is from Draftomania to Schizophrenia, and we will talk about schizophrenia, but just to let you know, we do see examples of misdiagnosis of bipolar disorder, over-diagnosis of bipolar disorder, because an African-American patient may be incorrectly diagnosed as having a manic episode because they tend to be more expressive or colorful. This is something that Annelle Prem and William Lawson have written about significantly over the years, so it's something that you can look into. And also, I don't see that slide, but also mistrauma in children frequently. Mistrauma is something that we see children being diagnosed with oppositional defiant disorder and things like that instead of identifying the root causes and asking what happened to these children and missing traumatic experiences and missing diagnoses like PTSD. So, I don't know if you're familiar with this. This is an ad for HowlDoll. It has a kind of aggressive-looking James Brown-like man with his fist raised and HowlDoll advertisement from 1974, and you can find this in Jonathan Metzl's book, The Protest Psychosis, and this is when we really saw, in the early 60s and 70s, when people again requested liberation, again standing up for their rights, civil rights, and social justice, and they were more likely to be diagnosed with schizophrenia and psychotic disorders, and this is something that you can literally go back and see the numbers, see the data on since the 70s and beyond. So, since the 1970s, researchers have found that African-American patients' manic symptoms, also depressive symptoms, are under-emphasized. African-American patients are at a higher risk than white patients of being misdiagnosed with schizophrenia or a psychotic spectrum disorder, although the majority of epidemiological studies show that there is no difference in the prevalence of primary psychotic disorders. So, as I've said multiple times, we can see this from diagnosis to treatment to assessment to even how you interact with patients. Evidence demonstrates that these disparities are caused by multiple factors, ranging from clinician bias during the interview, the formulation process to racial differences in the patient's presentation, and really just not further digging into and understanding what's happening. An African-American who is admitted to an inpatient psychiatry floor is almost two times as likely as a white person to be diagnosed with schizophrenia and half as likely to be diagnosed with an affective disorder. Okay, here's the missed trauma slide, I'm sorry, earlier, and then again, we see it in treatment planning, in the choices for medications that are given, in the level of care. The level of care for African-American patients are more likely to be treated for psychiatric illnesses involuntarily. Hospitalized African-American patients are four times more likely than their white patients to be placed in seclusion and restrained. Back in 2019, we wrote the book Racism and Psychiatry and the clinician bias and diagnosis and treatment chapter that I worked on, we reported what we found across the board is that African-American patients are more likely to be on first-generation antipsychotics, more likely to be given IM depo medications more frequently, more likely to be given, not to be given adjunctive medications, and they're giving antipsychotics at much higher doses. Also, I just have to mention, again, also from 2019, the buprenorphine treatment divide by race and ethnicity and payment, a JAMA article, which is very pivotal, that showed us that buprenorphine treatment was concentrated among white persons and those with private insurance or self-pay. People admitted that they were not offering African-American patients or patients with Medicaid buprenorphine or Suboxone treatment without any reason other than their race or their ability to pay without insurance or medical assistance. So, when we think about all the things that are happening, we've always been trained to care for individuals, but sometimes systemic issues are being mislabeled and mistreated as an individual issue, and you really have to understand that systemic racism, society, and institutional policies and cultural norms really have an impact on what your patients are experiencing. Individuals are a part of a system. However, they are individuals, and the system is acting on them every day in every aspect of their lives. So, we've seen, maybe more than any other group, we have seen the COVID-19 pandemic affect Black and Brown, Black and Latinx communities at a much higher rate, and is the reason because of their race? No, the reason is because of racism. So, really, when we think about social determinants of health, we really need to consider that racism is the social determinant of health, and these things, these disparities and inequities that we see are really because of a multitude of reasons, including a lack of providers from diverse and racial ethnic backgrounds. These are things that go back to, like, the Flexner report that closed multiple HBCU medical schools and limited the number of Black physicians in this country. Housing, food security, employment, transportation, mistrust of the health care system, and under-insurance and stigma, these are all things that are frequently acting on your patients and affect their access to care. Now, when we think about just medicine and therapy, do we consider how all these disparities contribute to the inequities that our patients face? So, I mentioned earlier about redlining. I mentioned earlier about discriminatory housing practices. So, I just want to, I'm going to turn off my camera here so that you can really just see this map. So, this map is of Washington, D.C., because I am here in D.C., and because the APA is here in D.C., but you can find these maps all across the country if you just Google redlining map of whatever city you happen to live in. So, again, I'm not a historian, but I do like to talk about how history has impacted us. So, if you just look at the map and think about it, in the 1930s, a federal agency, the Homeowners Loan Corporation, HOLC for short, created residential security maps of American cities. Red areas were deemed hazardous, and there was a systemic denial of loans of home ownership. This is redlining, and this is a predatory lending practice that was supported by the federal government. It created insular neighborhoods, which people called the ghettos, and the U.S. government and Supreme Court determined that education can be funded at a local level, and this is determined by taxes. What determines taxes? Property values. So, these things also determine housing, determine where there are medical deserts, where there are food deserts, where there is no transportation or limited transportation. So, people are trapped here in these insular neighborhoods created by predatory lending, and this is also, though, where their social networks are, and it's hard for them to move out or to obtain loans or to even have the option to rent elsewhere. So, this is a systemic problem that is often framed as an individual problem when it comes to your clinic, when it comes to access to care, when it comes to your patients being quote-unquote compliant and showing up on times for appointments. Alright, I'm back. So, we are not without history, so that says we're not our history, but we are not without history. It's important to understand how all these experiences, these risks and trauma affect your patients, affect your colleagues as well, and clinicians who focus solely on treating the presenting symptoms without giving consideration to the social, political, historical context are destined to be inadequate. Generational trauma in BIPOC communities, intergenerational trauma is suffered by one generation to the next. It can be individual or it can be collective, but it's passed on to future generations because, again, we are not without history. We cannot ignore these things. Intergenerational trauma is defined as a transmission of historical oppression and its negative consequences across generations. So, individuals are a part of a system, yes, and you treat the individuals, and I'm not saying that it's up to one psychiatrist, one physician, one resident, one medical student to change the whole system. This is going to take an institutional effort. Yes, this is true, but really, what can you do when you're starting to think about treating your patients? Instead of treating them in a way where you consider compliance of the goal, really work on understanding the social determinants of health and what is impacting your patients and how systemic racism is really the chief, one of the chief factors, including economics and socioeconomic status, affecting this, influencing social determinants of health. Are you asking them how racism is impacting them? Are you wondering why they're late for their appointment or why they can't make it? Are you asking them about these things? Are you addressing these things? Are you creating collaborative treatment goals? These things are important because we are not without history. We are not just individuals moving through in a silo. We are part of systems, so therefore, the system needs to be addressed as well. Interdisciplinary treatment planning is important. I will say that I happened to work in a clinic where we noticed that there were a lot, a high rate of no-shows. People were late for their appointments frequently, and people were coming from wards across the city, and when we were able to obtain funding to provide lifts or shared driving, shared ride shares, I'm sorry, ride-share opportunities for our patients where we could send a lift or, I'm not sure if I'm allowed to say lift, but ride-share, to pick them up, we saw an increase in their access because they didn't have to take two or three buses and a train to get to their appointments because, again, they live in a medical desert. Things like that are things that we need to take into account. Clinical implications. What can we do clinically to change the system, to change the institution? What can we do? So, other specialties have been doing a really good job with this, and I would just really like to recommend that you read Structural Racism for a 60-year-old Black woman with breast cancer in the New England Journal of Medicine, and this is actually an oncology article, but they have three points that I find that are very important. Clinicians can make the invisible visible, and what do they mean and what do I mean by this and why do I want this to be emphasized?, because if you see something, you can bring it to the surface. You can allow this to be questioned. You don't have to allow this cultural norm to continue to persist. If you see someone giving a patient who happens to be a Black male who is at higher risk for EPS, high doses of an antipsychotic, for, it just does not seem to be clinically indicated, ask the question. It might be challenging, depending on what level you are at, but ask the question. Ask the question. You can make the invisible visible. Healthcare organizations can engage in the communities that they exist in. Ask people what they need. Ask people, make this effort to change the accepted explanatory narrative, like, oh, well, Black people just don't go to therapy. That's just what it is. Ask people what they need to be willing to engage. Institutions can make systemic changes to eliminate structural racism and to eliminate these structures that are in place. Is it going to happen overnight? No. Is it going to happen in one year? Is it going to happen in one pandemic from 2019 to 2021? No, but you can start to make a difference. Avoid performance of allyship. Really ask yourself and recognize that, when you say that you are an ally, is that what's really needed? Are we, do we need more people making Black Lives Matter posts, or do we need more sponsors and advocates? And when I say a sponsor, I mean someone who puts their resources to work. A resource can be money. It can be funding. It can be time. It can be effort. It can be reference to people, and advocate for your patients. Advocate for your medical students when you hear them. Residents, when you hear them saying that they're going through things, when you hear them say that there is no one else here at this hospital who looks like me, I'm the only Black, insert medical student, resident, faculty member, listen to them and really decide to be intentional and make a change. It's going to be a cultural shift. It's not something that can happen just over, overnight. How can we reduce and eliminate our own biases? Three steps that I'm going to recommend, because I know that we're getting a little bit closer to the end of my time, and I definitely want to have some time for questions. How can we reduce and eliminate your own bias? One, acknowledge that racism exists. Acknowledge that biases exist. Everyone has them. Acknowledge that racism exists. Do not participate in the, one of my most hated things, do not participate in the statement that I'm colorblind, I don't see color. That can be very harmful. It can be, it has potential to ruin your relationships with your patients. It has potential to ruin your relationship with colleagues and with your trainees, because if you're saying, I don't see color, I treat everyone the same, you are ignoring a crucial and important, a vital part of their identity and their experience, because things have been for generations, as I said, we are not without history, and you do not know when someone takes off their white coat, when someone takes off their white coat or their Patagonia, and they step into the outside of the hospital or the medical education walls, what their experience is like, so for you to say, I don't see color, I'm, I treat everyone the same, you are ignoring something very important. Ask uncomfortable questions, and this goes back to what I was saying about clinicians or physicians or psychiatrists, insert whatever you want, are able to make the invisible visible, bring it to the surface. I had an experience where a ED physician was prescribing very high doses of an antipsychotic, of Haldol, for a patient who we didn't have any information of, we did, about, we did not know if the patient was psychotropic naive, and I asked, you know, why did you give this patient this high dose of an antipsychotic plus this high dose of a benzo? Why did you learn that?, and the doctors told me, oh, well, that's what I learned in my training, that black patients are able to tolerate higher doses of antipsychotics, which is exactly incorrect, which studies have shown that, but if I didn't challenge that, and I challenged that in front of the physician, of course, but in front of my residents and medical students as well, because we have to ask uncomfortable questions, and most importantly, we have to ask ourselves, is this the standard of care? Is this what you would want given to yourself? Is this what you want given to your family member? Is this how you treat all patients? These are ways, simple steps, that you can work on potential solutions on a micro level of eliminating, I know, eliminating strong, but at least reducing your own biases, so take-home points for today. Um, when we think about racism in psychiatry, racism and psychiatry have gone hand-in-hand for years, historically and currently, from drastomania to the over-diagnosis of schizophrenia to the higher use of antipsychotics to the higher level of care for black patients, things that we see. It happened. We have to recognize that. We have to own that. Social determinants of health are directly tied to socioeconomic class, education, including health literacy, and also systemic racism's barriers that have put in place. It's that continuous cycle that I was talking about. One feeds into the other, and barriers to access to care are multilevel and multifactorial, so when you're trying to figure out how to best help your patients, if you're trying to figure out why they're not compliant or adherent to the treatment that you just gave them, try to understand all the things, all the factors that are impacting them. Do they have to decide if they're coming to your appointment, or do they have someone to watch their children, or how much money is it going to take them to get across town to your appointment, to your office? Do they have, do they have data on their phone to fight this digital divide, now that everything was telemedicine and tele-psych? Do they even have a smartphone? Do they have access to a computer? Really think about that. I am now quoted and known for saying during the first Structural Racism Task Force town hall that, when Black people go through a crisis, White people have a book club, but I definitely want to say that we do have the opportunity to educate ourselves, and these are some books that I definitely recommend. Harriet Washington, these two, especially, if you only choose one, I would go with Medical Apartheid, really explains and takes a deep dive into the history of medical racism, medical experimentation on Black Americans from colonial times to the present. Not everything that I discussed in the beginning, but some of those things are discussed in her book, and I'm talking about from psychiatry to sterilization, forced sterilization to all types of experimentation. Also, again, I would recommend looking up the Aspen Institute and the 2016-11 Terms That You Should Know. Anyone should know, and you can share and post as well, and the book that Morgan Medlock, definitely a leader of all leaders in this realm, that I was a co-author for, that I wrote about the impact of the apocalypse on me later today, because I wrote about it. I don't know who that is, but I can't see, but why don't we walk in here? So, Racism and Psychiatry, definitely a book to look into. The Process Psychosis by Jonathan Metzl, if you're really interested in the path of schizophrenia across this country, really understanding how schizophrenia became a quote-unquote black disease, I definitely recommend that, and Why Are All the Black Kids Sitting Together in the Cafeteria by Beverly Daniel. Tatum is a little bit older, but it's definitely great, especially for those of you who practice in the CAP or child psych realm. This is how you can find me. I am on Twitter and Instagram as a doc named Dani. I do have a platform called At Black Psychiatry that assembles panelists from all across the country to discuss all things that happen with black mental health topics, from parenting to women to black men to substance use. It's all free, and the content is available at any time on YouTube at Black Psychiatry, so if you have questions, I'm going to let Dr. Demi take over here. Thank you so much for that talk. I learned a lot during that talk, which is fantastic. We do have a question in the chat, and I'm going to read out the question, but I'm not sure who asked the specific question, and so, if that person wants to chime in at any point to kind of clarify in any parts of it, please do so. So, the question is, are we assuming that DIPA medication is safe for people with schizophrenia? If so, please do so. So, the question is, are we assuming that DIPA medications constitute better care or worse care? In my world, DIPA medications show that clinicians are attentive to providing optimal care. Might public facilities be doing a better job by providing more DIPA preparations to their patients? So, thank you for that question. The question is coming from, so I'm not making an assumption either way. I'm not making the assumption that DIPA medications constitute better or worse care. I'm just making the statement and showing the data that DIPA medications are more likely to be used in black patients, particularly black male patients, instead of giving other options, instead of giving things like options like participating in a PHP or a day program or an IOP so that you are closely monitored, and maybe you are at the place where you don't have to have a DIPA medication. Obviously, we know that there are very sick patients who belong to all different racial groups who need and benefit from DIPA medications, so I wouldn't make the assumption that DIPA medications constitute better or worse care. I'm saying that what we have seen is that higher levels of these medications are given to black patients, higher levels of care, seclusion, restraints are given to black patients, which is a bias and perpetuates a stereotype that black patients need these high levels of medications. Black patients need to have a DIPA medication, which are not always offered to their white counterparts, but thank you for the question. Thank you for that. I have a question. So, I engage a lot in first-episode psychosis and the pathways to care for black families, and what constantly comes up is the over-diagnosis of schizophrenia among black individuals, which has, there's so much literature out there that dates back to the over-diagnosis of that, and so questions that I get from clinicians is it, because we tend to see this for first-episode psychosis as well and that there seems to be a higher incidence rate for racially and ethnically diverse groups in terms of first-episode psychosis, and so I always wonder what the balance is. Is it an over-diagnosis, which may constitute some of that clinician bias, and then how much of it, how much do we rely on the data that is presented to us if we know that there is this bias in the over-diagnosis of schizophrenia? Well, I'll have to have like a whole other talk just on that, but how much of it is bias? I think a lot. I think a lot, and just, it's not just the bias that we have within ourselves. I think that it's the, again, systemic and structural that this is put in place, that you are trained to think, okay, this is how schizophrenia presents. When you see a black male or a black, a young black woman coming in with this, this is likely schizophrenia. Do you ask further questions, though? Do you ask, were they using a substance at that time? Do you really delve in to tease out things? Do you understand if they're actually having mood symptoms at the same time, if anything traumatic has happened to them that has led to this flat affect? If you ask these questions further, and a lot of the times the answer, as we have seen time and time again, I appreciate, you know, our ancestors and senior and seasoned researchers really looking at this, that we have seen time and time again that these questions are not asked and that it's, even when a patient comes in with the same exact symptoms, a black patient and a white patient, black patients are more likely to be diagnosed with schizophrenia. The other patients, they ask questions about mood. They ask questions about trauma, and why is this consistently something that we see, because it's a system that is reinforced by, of course, individual practices, but it's a system that allows this to be perpetuated, so I guess your question was how much of it is a lot of it. Yeah, I think it's super tricky, because we have this emphasis on research, and this is what it highlights, but it's really hard to capture how much of it is clinician bias, and so then we teeter this line between, oh, the data, this is what the data is showing us. This is who we see in actual practice, but we know that these biases and these disparities exist, and so it's like the struggle point between what the data is telling us to what we actually know is actually happening, but I think we are at 10 o'clock, and if anybody has any questions, Dr. Hairston has provided her contact information, I think, on the previous slide, so please contact her or even contact people at ABA that can get in touch with her for you, and like I said earlier in the presentation, please follow these instructions on how to claim your credit, especially in regards to getting those CME credits. I would like to thank you once again, Dr. Hairston, for doing this webinar. It's super educational, and I think it will be provided for individuals that weren't able to capture it at a later date, so thank you. It will be, it was recorded. I'm not sure when it will be up, but it will be up. The slides, we'll have to ask Evan. I think the slides will be available as well. Yes, you can always ask me questions on Twitter. On Instagram, I'm much nicer. On Twitter, people come for me, and I have to film myself, but yes, it will be available, and I want to thank the APA. I want to thank Morehouse. I'm an HBCU enthusiast, so I want to thank Morehouse for inviting me here, and I hope that we learned a lot, and I look forward to future discussions.

webinar

mental health

racism

healthcare

bias

psychiatry

systemic issues

patient care

diverse racial backgrounds