Hi. Welcome to San Francisco. We'll go ahead and get started with some of the bookkeeping aspects. Just a reminder, I'm Dr. Mata. I'm the moderator of this session. I'll be also facilitating the question and answer session afterwards. I'll make sure that before the Q&A begins, if you could step up to the microphone so that we can hear the questions. To introduce Dr. Dilip Jesti, it's my great pleasure. He is a former Senior Associate Dean for Healthy Aging and Senior Care and Distinguished Professor of Psychiatry and Neurosciences at University of California, San Diego. His main areas of interest in research include schizophrenia, neuropsychiatric interventions, and healthy aging. He has published 15 books, over 750 peer-reviewed journal articles, over 160 invited book chapters. He's also the past president of the American Psychiatric Association and the American Association for Geriatric Psychiatry. He's a member of the National Academy of Medicine and is Editor-in-Chief of International Psychogeriatrics. He's also a TEDMED speaker. It's my great privilege to introduce this distinguished psychiatrist lecture, From Racism to Wisdom, Critical Role of Social and Psychological Determinants of Health in Psychiatry. Dr. Jesti. Hi. Good afternoon, and thank you Dr. Martha for such a kind introduction. I should mention that she's the only person I know who is board certified four times in four different areas. Quadruple board certified. So, it's really a pleasure to be in this area. So, thank you all for coming. I know there are so many concurrent sessions going on, so I appreciate your being here. So, I'm going to talk on Racism to Wisdom, Role of Social and Psychological Determinants of Health in Psychiatry. So, I don't have any relevant conflicts of interest. I'm going to begin with, what are social determinants of health? What do they mean? Why should we bother about them? Then the next two topics are more on the dark side. The social anomie, behavioral pandemics like loneliness, suicides, opioid use that we have been experiencing for the last few decades. Then another one that has become prominent in recent years, racism. But then we switch to something positive, bright wisdom, and then positive psychiatry interventions at individual and societal level. So, social determinants of health. The idea that social factors are important in health is not new at all. In the 6th century BCE, the Greeks considered physical and social determinants of health and they emphasized supportive environment and healthy public policy. And this is a beautiful quote by Rudolf Wercker. He was a neuropathologist, but he said that in 1840, that if medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society? It was the World Health Organization, or WHO, that first published a book on social determinants of health in 1998. And they followed that with books in 2002, 2008, and they really brought this issue to the fore for the whole world. And, believe it or not, in 2021, in the US, a new bipartisan congressional caucus on social determinants of health was established. So now we all can be sure that the Congress will handle all of the social determinants of health and we'll all live happily ever after, right? So, the Congressional Caucus. Yeah. So what are social determinants? The WHO defined them as the conditions in the environments in which people are born, live, learn, work, play, worship, and age that have a major impact on health as well as health inequity. They account for 30% to 55% of health outcomes, including longevity, and that proportion exceeds the contribution from the health sector. So factors like hypertension, diabetes, obesity, smoking, they have less impact on health and longevity than the social factors. And that's why the WHO said, rightly, that addressing the social determinants of health is fundamental for improving individual and population health and requires action by all the sectors of a civil society. These are the results of a large meta-analysis that was done by Julian Holt-Lunstad, an epidemiologist at the Brigham Young University in Utah. So you see a number of bars, right? Each bar represents the odds of reduced mortality. So the longer the bar, that means the better it is. And it lists the various factors which were studied, starting with social relationships and then various other things like smoking, hypertension, and so on. So what you can see immediately is that the first three bars, the top three bars, which relate to social relationships, are significantly better than all the remaining factors. And the remaining factors include smoking, sedentary behavior, obesity, hypertension, and even climate change. So this shows that social relationship has greater impact on health and longevity than other factors. So that is about social determinants of health. Do we really need social determinants of mental health? Two years ago, Dr. Vivian Pender became the president of the APA. She's on the faculty at Cornell, and she made social determinants of mental health her presidential theme, and she appointed a task force. And she made me the chair of that task force. And that's how, actually, we started doing work in this area. And we published a paper next year in JAMA Psychiatry on why we need to even think about social determinants of mental health different from social determinants of physical health. Several reasons. And these are not happy reasons. These are sad reasons. So 75% of the serious mental illnesses begin in early life. Schizophrenia, bipolar, depression, substance use, ADHD. 75% they begin in childhood, adolescence, or early 20s. And then this is something which should be utterly embarrassing for us in the US. More people with serious mental illnesses in the US are in jails and prisons than in hospitals. The literature shows how our criminal justice system is so flawed that we equate mental illnesses with criminality. There's also a big mortality gap between people with serious mental illnesses and the general population. People with schizophrenia die 15 to 20 years younger than the general population. 15 to 20 years. And we published a paper that showed that the mortality gap actually has been increasing in the last 40 years. It is not increasing because people with schizophrenia are dying faster. It is increasing because the general population is doing better. You know, in general, nutrition has improved. We have better medication for caring for various different things. People are getting physically more active, et cetera, et cetera. But those advantages have not gone to people with serious mental illnesses. So we propose that there are some factors that should be social determinants of mental health that we in psychiatry must focus on. They include stigma against mental illness, health care inequities. Here in the US, again, getting reimbursed for mental health care is much harder than getting reimbursed for cancer, diabetes, and various other physical conditions. Criminal justice system is clearly so flawed where people are kept in prison because they had a delusion, and in the effect of delusion, they did something wrong. Homelessness, major problem, especially for people with mental illnesses and substance use disorders. And social media. Social media have been so positive, but not for people with mental illnesses or susceptibility to mental illness. The number of suicides related to Facebook and Twitter really have gone up. So social determinants of mental health have become increasingly important in recent years. At the same time, how do they affect health and longevity? They must impact biology, and they do. So a number of studies have shown that the early life adversity, the thing that happened prenatally, postnatally, in early life, they affect the expression of genes which is responsible for good health. So there's what is called social epigenetics. Allostatic load, that means load of stress, which produces increasing problem. Accelerated ageing. People with schizophrenia die young because they're ageing faster. So a 45-year-old person with schizophrenia is like a 65-year-old normal person. And this accelerated ageing, mainly because of the inflammation, so it's accelerated inflammation. Microbiome. There's increasing evidence that the bacteria, fungi, viruses we have in our gut, and not just in the gut, even in the skin and other parts of the body, they have a major impact on mental health. There is something called gut-brain axis. They affect immune function, they affect brain function and brain structure, and vice versa. So brain impacts microbiome, and microbiome impacts brain. So those are the systemic pathophysiologic processes, and then they impact the brain. They impact structure of the brain, function of the brain, neurochemistry, and neuroplasticity. There is something called social brain. So these are specific parts of the prefrontal, as well as temporal and parietal lobes that are involved in socialization processes, and that's called social brain that is being studied. So that's a sort of brief background about social determinants of health, why the social factors are important, why we should worry about them. Then comes social anomie. Some of you probably have heard of Durkheim, Emerald Durkheim, who first used the word social anomie. And in recent years, there has been growing research on that. Social anomie is a state of society and a state of mind, both, characterized by disruption and disintegration. Disintegration. So there's social disruption, social interruption, and also something with the mental level, resulting in loneliness, depression, and suicides. So, for example, during World War II, or Holocaust, or when there is long depression, financial depression, et cetera, those things impact the society's well-being. There's some very interesting article published a couple of years ago. This is a study done in the UK, using the amazing UK Biobank, which has data on nearly half a million UK residents. And it's really fascinating research. They found that the local stock market index fluctuations impacted the society's and individuals' mood, alcohol intake, and blood pressure, and even beyond that, in a sub-sample, about 40,000 people in whom they had brain MRI, they found it also impacted effective brain regions over a five-and-a-half-year period. And this is even after adjusting for potential confounders. So that means these kind of social things, stock market fluctuations, impact on the economy, has impact on the social mood and on the brain structure. So that brings us to pandemics. So when we talk about pandemic, of course we know about COVID, but typically we think about global epidemics caused by infections, right? Plague, cholera, flu, and of course now COVID-19. Millions of people have died throughout the centuries. What we don't talk about are the behavioral pandemics. These are pandemics not caused by any bacteria, viruses, anything like that. They're behavioral problems. And I will talk about these briefly, especially loneliness I'm going to focus on. Also, suicidality and opioid crisis. This is something that has been going on for the last three decades in the U.S., but also in the rest of the world. So I want to spend a few minutes talking about loneliness. What is loneliness? And this is a really beautiful book written by a British historian, Faye Alberti, Biography of Loneliness. She said that the word loneliness did not exist in English language until 1800. The word that existed was oneliness, in the sense it didn't have L from loneliness, but the oneliness existed. And it's not only a difference in that one letter. The difference is in what it meant. You know, loneliness is defined as subjective distress caused by feeling that you're alone, isolated. Oneliness meant being alone, but it didn't cause distress. It was not undesirable. Actually, in some ways it was good because it provided you with space for reflection with God. And God is always there, so a person was never truly alone. So the idea about oneliness and being alone was actually a positive idea until 1800. So why did it change in 1800? That is when the industrial revolution started in the early part of the 19th century. In the early part of the 19th century. And with the industrial revolution, really the society changed a lot all over the world. There's growth of consumer economy, declining influence of religion, popularity of evolutionary biology, Darwin's hypothesis of survival of the fittest. So Darwin was talking about species, that the more powerful you are as a species, more likely to survive. But that also applied to individuals. And the result was the society became much more individualistic instead of the traditional paternalistic versions of a society in which everybody had a place. So in the agricultural society, we were all a big family, big community, all together. But with industrialization, we became more separate. The families became smaller, divorce rates increased, religiosity went down. And this kind of loneliness increased. Again, this is Dr. Fay Albert's write-up, which makes a lot of sense. And then, I think many of you must have read this in all the newspapers and media just two weeks ago. Our Surgeon General, Vivek Murthy, talked about epidemic of loneliness in the US. This is a major report that came from the CDC. Loneliness is a silent killer. It increases the odds of mortality by 30%. It is as dangerous to health as smoking 15 cigarettes a day and more dangerous than mild to moderate obesity. Why? Because loneliness increases the risk of heart disease, diabetes, obesity, major depression with suicide, opioid and alcohol use, Alzheimer's disease, and other dementia. This is all based on strong empirical evidence. Longitudinal studies have shown that people who are lonely at baseline are much more likely to develop these various illnesses and then die. So it is not just some fiction. And it is not just a healthcare issue. It's a business and government issue. UK was the first to actually establish a Ministry of Loneliness back in 2018. And then three years later, Japan also established a new Ministry of Loneliness. So these are actually major issues for the whole society. And in the US, you can see how these problems have increased. Suicide, the rate of suicide in the US increased by 33%. And these are CDC data. Okay, so they are true, right? In both men and women. Opioid use. In 1999, 8,000 Americans died from opioid use-related deaths. Today, that number is 100,000. More than tenfold increase in what is called deaths of despair from opioid use and suicide. So what is happening? Why is this happening in the last 20, 30 years? But there is something happening. And average lifespan in the US fell for the first time since the 1950s, before COVID, you know, we all talk about how, you know, longevity has gone down after COVID, but it happened before COVID. And yet nobody paid any attention to that. And that is because it's a behavioral pandemic, right? So and that's where the social factors become important, because they affect our health, they affect our longevity. And we've got to do something about that. And one factor that has become especially prominent in the US, especially in the last few years is racism. So there are multiple forms of racism. The most important in some ways is structural racism, I'll talk about that. But then institutional racism in specific institutions you work with, and interpersonal racism at individual level. But the structural racism that really affects the whole social structure, it refers to how the society and its systems cause avoidable and unfair inequities in access to power, access to resources, access to capacity, and opportunities for marginalized groups. So the groups that are discriminated against, they have far less chance of getting resources, capacities, power that are needed to succeed in life. And how common is racism? This was a study published three years ago, based on data from Pew Research Center. It was a study of 3,716 American adults. And they found that 50 to 75% of black, Hispanic, and Asian Americans reported discriminatory treatment. That's a huge number. That means majority of people from minority communities experience racism. Canada, this is a more recent study, in Canada 46% of black persons experienced discrimination in 2019, compared to 28% in 2014. So just in five years, the number of people experiencing racism had increased so much. And I think that also has happened in US, and also in Europe, increasingly that is happening with immigration, there is more bias against minority communities. And in the Canadian study, they found that discrimination is also more common among the indigenous population than in the non-indigenous population, 33% versus 16%, twice as much in the indigenous population. So it is, again, something that seems to be growing, this discrimination of minority communities. So this clearly means that we should assess racism, right? How do we assess racism? Well, actually there are scales to assess racism. So there are several scales that have been validated to measure individual experiences of discrimination due to race or ethnicity. One is perceived racism scale, another is experience of discrimination questionnaire, and the third one is everyday discrimination scale, which has a subscale called lifetime discrimination. So typically what these scales include, they have a bunch of items, and you give them to marginalized communities, and you ask how much experience you have had about discrimination, and then you rate that inequality from one to five, something like that, right? But that is at the individual level. What about the larger level, community level, structural, institutional, interpersonal? There are scales. One is perceived ethnic discrimination questionnaire, community version, and another is lifetime exposure discrimination subscale. So here, it's like CDC. Instead of questioning individual patient, you question the whole community, have them complete the scale, and you get an idea about discrimination, racism there. Another is called institutional racism subscale of the index of race-related stress. So the good news is that there are scales we can use that are not commonly used at all, but they exist. But then I have a question that how do we assess racism among potential practitioners of racism? So whom do we give these scales? We give these scales to marginalized communities, communities that are facing racism. But we don't give them to the majority of the community. So the question we will have to ask them is rate yourself on how racist you are on a one to five scale. How many people are actually going to rate themselves as racist? I mean, almost nobody, because most people who are racist, they don't think about themselves as being racist. They have some logic behind what they do. But really, we need to think about that, even from a scientific perspective, about how do we assess racism in non-discriminated population, just to think about that. Racism and schizophrenia, why should we worry about it in psychiatry? So we published actually one of the first papers, I would say, on scoping review of racism, not just racism, but a bunch of social determinants in schizophrenia spectrum disorders. And Dr. Subodh Dubey, who is here, the dean of the Royal College of Psychiatry, is one of the co-authors. And really, we are developing a global research network to study the social determinants. So we looked at this meta-analysis of 70 studies, including 33,000 participants. And this is really amazing. Perceived racial or ethnic discrimination was associated with elevated risk of developing psychotic symptoms, odds ratio of 1.82, or psychotic experiences, odds ratio of 1.94. It's almost twice high. That means if you are a black person, or some other racially minoritized population, you have almost twice the chance of being diagnosed with schizophrenia. Why? So this is not biology, 100%. It is not biology. Why? Because the incidence of schizophrenia is the same all over the world. The incidence of schizophrenia is 1% lifetime incidence in Asia, Africa, Europe, North America, South America, Australia, New Zealand, everywhere, it is the same. So clearly there is no genetic susceptibility for specific races, right? The second explanation is that clinician bias. And there is some evidence that white physicians, for example, they're more likely to diagnose schizophrenia rather than bipolar in a black person. But I don't think really that is the main explanation. That is true for some cases, but not for most. In most cases, actually what is happening is it is a marginalization, exclusion of the minority communities by the majority community that exposes them to multiple disadvantages. Starting with low socioeconomic status, again, most people from these minoritized communities, they have a hard time getting a good job. They have a hard time getting a good education, good job, et cetera. So poverty is a major issue. Social fragmentation, social isolation, Hispanics, for example, again, those who migrated, they often have difficulty being accepted by the non-Spanish speaking community. Early life adversities begin in utero. If you have a pregnant black or Hispanic or other marginalized woman, the fetus suffers from day one, the day one of embryo, because the mother doesn't have enough nutrition, socioeconomic advantages, multiple infections. So the baby is born with a number of disadvantages at the very time. So naturally, those are factors contributing to the risk of schizophrenia. And there's, of course, greater mental health stigma which leads to delayed treatment. Okay. Biology. Again, we got to study biology because then we can, in future, develop some biological intervention. So how does racism affect biology? Very nice review published just last year by Muscatel. He showed that racism was associated with greater allostatic load. So that means excessive stress. And that leads to epigenetic changes affecting the gene expression for things that matter. Also that leads to then disrupted connectivity in the brain between the salience network, default mode network, executive control network, which leads to greater sympathetic neurosystem signaling, HP axis activation, increased expression of pro-inflammatory genes. And this pathology persists because you face racism throughout the life, which leads to accelerated aging, accelerated biological aging. So shorter lifespan, increased morbidity. So you can see, actually, how those factors impact the health and longevity throughout life. Yes. This is something not too many people know, but it's a shocking factor. In the U.S., one of the best predictors of mortality is the zip code. Isn't it amazing that the social factor, where you live, determines how long you are going to live? And that's because of the type of health care you get, the people who are there, and the neighborhood, socioeconomic status, so on and so forth. Okay. So these are all bad things happening. So what do we do? Well, there is some good news. There are things we can do to change things. And the first thing I want to talk about is wisdom. So wisdom has been known, of course, from the times immemorial. All the religions and philosophies have wisdom. There are, I think, about a dozen books of wisdom in the Bible. But empirical research on wisdom is recent. It started only about 40 years ago. But the research has been increasing. And there are 2,000 papers on wisdom in peer-reviewed journals published in the last decade. Again, it's not enough, but at least it is increasing. So what is wisdom? Wisdom is a personality trait. It's a trait like resilience, optimism, extroversion, introversion, characteristic pattern of behavior in an individual. It is complex because it has multiple components. What are the components? The most important one is pro-social behavior, the things that you do to help others, empathy and compassion. Then comes emotional regulation. Think about a teenager. You know, emotions fluctuate over minute to minute, and think about a wise older person. But emotional regulation with positivity, that's important, higher well-being. Self-reflection, ability to look inwards, try to understand yourself. Accepting uncertainty and especially accepting diversity of perspectives. We live in a very polarized world today. People who don't agree with us, they must be either evil or dumb. And the whole world, actually, I mean, it's not just in the U.S. You see that all over the world, and not only in politics, in other ways also, unfortunately. That's not wisdom, to be sure. Decisiveness. Decisiveness doesn't mean making a quick decision. It means making a rational decision. And last is spirituality. There are some people who don't think much about spirituality, but there is emerging evidence, really, that spirituality actually is a major component, not only of wisdom, but also of longevity, a contributor. Actually, this Wednesday morning, Alexander is here, going to chair a course on spirituality and religiosity. It's important. Okay. So the next question is, of course, how do you measure wisdom? So we developed a scale called San Diego Wisdom Scale. It's a 28-item version and 7-item versions. And each item is to be rated on a scale from 1 to 5. Strongly disagree to strongly agree. Good to excellent psychometric properties. Translated into several languages. Examples of items. It is important that I understand the reasons for my actions. So you're really looking at self-reflection, right? Trying to understand reasons for your action. Another is I have trouble thinking clearly when I'm upset. So there's a lack of emotional regulation. If I'm upset, I really can't think logically. So that's not good, right? So there are some items that are positively worded, some negatively worded. And you say to what extent you agree or disagree as they apply to you. I'm a geriatric psychiatrist, so one of my interests is what happens to wisdom and aging. I come from India and those of us who come from Eastern cultures, there's a belief that older people are wiser. Wisdom increases with aging. And is that true? Well, there are a number of studies have shown that older people are better than younger ones in some abilities. Younger people are better clearly in some abilities like psychomotor speed, ability to learn new things, strong memory, etc. So that clearly younger people are better. But older people are better on emotional regulation, positivity, that is favoring positive emotions and memory, empathy and compassion, that is pro-social behavior, self-reflection, and experience-based decision-making because experience comes with age. These are all components of wisdom, right? So, there is clearly some empirical evidence that older people tend to be wiser than younger ones. Again, this doesn't apply to everyone. There are some young people who are very wise and some old people who are very unwise. But by and large, it's true. So, wisdom and aging. Actually, this raises another question. Again, as a geriatric psychiatrist, one of the questions I had was, why do humans live so long? If you follow Darwin's hypothesis of survival of the fittest, this hypothesis says that animals die soon after they lose their fertility. And that makes total sense, right? You know, for a species to survive, you must have enough animals. The older animals die. So, they have to be replaced with babies. So, so long as you can produce babies, you're useful to the society and species. When you stop producing babies, you're no good and you die. That doesn't happen in humans. Our age of menopause in women and menopause in men is around 45-50, but we live to 80-90. So, there is something called grandmother hypothesis of wisdom. What is the grandmother hypothesis? So, at the top, you see a couple. So, those are the grandparents. And especially the grandma is important. The middle one is an adult daughter. So, if the grandparents, especially the grandma, help the adult daughter, the children, the adult daughter lives longer. The adult daughter lives longer. She's happier, healthier, and she has time to produce more children. So, she produces three babies, whereas the mom produces two babies. So, the grandma cannot produce babies anymore. But she's helping the younger generation live longer, healthier, and produce more babies. So, that is why it's called grandmother hypothesis of wisdom. And this is, by the way, research done in humans, as well as bottlenose dolphins and killer whales, published in Nature and Science. The absolute top journals in any science, period. So, there's really strong empirical evidence for advantages of older animals to younger generations. And it goes beyond just this kind of evolutionary fertility benefit. You need older people to transmit social cognition and cultural values, like cooperation, to grandchildren. You need grandparents to be able to do that. The parents are too stressed out, as it is, and they have so many other things, that they are not able to do that. So, you need grandparents. So, again, I don't want to go into details, but there are specific regions of the brain that are more important in wisdom, mainly the prefrontal cortex and the limbic striatum. And within the prefrontal cortex, there is ventromedial, dorsolateral, anterior cingulate, and then ventral striatum, amygdala, and insole also plays an important role. So, I talked about possible increase in wisdom with aging, right? Those abilities increase. Emotional regulation with positivity, self-reflection, etc. How is that possible? Most of us, above a certain age, when we went to medical school, we were taught that the only thing that happens to the brain in old age is that it shrinks. It loses neurons, synapses, blood vessels, everything. That's actually not true. There is something called neuroplasticity of aging, but that applies only to people who are active. In people who are active, physically, cognitively, socially, throughout life, but especially in older age, there is greater recruitment and more efficient utilization of neuronal networks. And by the way, this is shown in multiple animal species and in humans too. There is formation of new synapses, synaptogenesis, and even formation of new neurons, not all over the brain, but in selected subcortical regions, like the dentate gyrus of the hippocampus and periventricular areas. And I also talked about positivity that increases with aging. How is that possible? So a number of brain imaging studies using fMRI and even PET scans and SPECT have shown that amygdala becomes less activated by negative emotional stimuli. For example, if you show the picture of a smiling baby to a young person and an older person, both of their amygdala will react in a similar way, they'll both be activated. But if you show the picture of say car accident, somebody hurt, somebody sad, in a younger person the amygdala will be quite activated, in an older person it will not be that activated. So in other words, older persons can handle stressful, negative things better than the younger ones. So all that, it means that there is biological basis for increase in wisdom in later life. And so starting about loneliness and how terrible it has been. So it is possible that wisdom may be a vaccine or antidote for loneliness. We have done four cross-sectional studies including several thousand people from U.S. as well as from Italy. And one longitudinal study in which we followed people for five to seven years. And we found people who had high ratings and wisdom and compassion at baseline, they're less likely to be lonely five to seven years later. Which also means if they're less lonely, they're less likely to develop hypertension, diabetes, obesity, they're more likely to live longer, right? And it is not just clinical, we found similar differences in associations of loneliness and wisdom on EEG and gut microbiome. So even biologically, loneliness and wisdom seem to go in opposite direction. So what can we learn from this? What can we do in our practice for ourselves, our families and especially for our patients? So and this is something we've got to do because as I said, we are living today in a very highly distressed world. Rates of suicide are growing up, opioid-related deaths are going up, depression, stress, anxiety. So what do we do? Well, one thing is we need to talk about something positive. Let us go beyond loneliness and depression and so on. We talked about, I talked about wisdom, but there are also other positive psychosocial determinants. One is resilience. Numerous studies, countless studies have shown that even in physically ill patients, resilience is associated with medically desirable behavior. Better self-care, better self-treatment, better exercise adherence, greater longevity. Optimism. There's a meta-analysis of 83 studies of optimism and they found that optimism was associated with better cardiovascular outcomes, better physiological markers, including immune function, better cancer outcome and lower mortality, all p-values less than .001, highly significant. By the way, many of these studies control for the thing that we want to control for, like past history, family history, use of statins, smoking. After controlling for all of them, optimism still was one of the best predictors of overall cardiovascular health. And actually the American College of, American Association of Cardiology has said that optimism is one of the best things to actually promote in our patients. Social engagement. Even stronger literature, 148 studies with a sample of more than 300,000 people, 50% increased likelihood of survival among socially engaged people compared to non-socially engaged people. And if you think about that resilience, optimism, social engagement, we can do something about those things. But we don't even talk about them, right, in medicine. So we need to change that. So 10 years ago, I was president of APA, right, actually, here in this place. And my main job was to publish DSM-5. And many people said, oh, DSM is the Bible of psychiatry. And I said, no, DSM is not a Bible of psychiatry. DSM is important, obviously, but psychiatry is more than illnesses. Psychiatry is mental health, not just mental illnesses, mental health. And mental health also has positive aspects to that. So I made actually positive psychiatry my presidential theme. So positive psychiatry is a science and practice of psychiatry that focuses on study and promotion of mental health and well-being through enhancement of positive psychosocial factors, like social relationships, wisdom, and resilience. And the reason for that is there is empirical evidence to support that. It is not some feel-good TV science, but there is strong empirical evidence. So what can we do? Again, in the practice today, I don't think there is any physician who ever asked about these things. And that is not our fault. The EHR doesn't require that, and nobody gets reimbursed for assessing those things. But we've got to do that, because our patients' lives actually depend on this. So there are some scales that are worth using. This experience of discrimination, childhood trauma, questionnaire, UCLA loneliness scale, on the positive side, social network schedule, San Diego Wisdom Scale, Connor Davidson Resilience Scale. And one of the things that our global research network is doing now is to develop some assessment tools that people can use in practice, something that is relatively brief. And again, it does not need to be given by a physician, or even a psychologist, or even a social worker. It can be given online, and it can be done by staff or non-professionals. We need anti-racist mental health care. Very nice article published in Lancet Psychiatry that talked about what is anti-racist mental health care. One is awareness of racial issues. We should keep those in mind. We should ask the patients about this issue when we see minoritized population. Sometimes we are reluctant to ask those questions, but if you don't ask, we won't know the answers. Assessments adapted to the real needs of minoritized individuals. There is, especially with medication, there are some studies that show that blacks, for example, are much more likely to be prescribed higher doses of antipsychotics than whites, when there is no other difference in the level of pathology. And that is, again, that is kind of subtle, even unconscious discrimination that may be occurring. At the same time, people do need medication. So again, so long as we keep that in mind, we are aware of that, and then make a conscious decision, that's useful. Treatment approach that addresses the real needs and issues related to racism experienced by minoritized individuals. Not asking about racism doesn't help. I think it is like what we used to do. Never ask the person about suicide, we were told, because then that makes them suicidal. It's just the opposite. We must ask them about suicidal ideation, because then we can do something about it. Same thing applies to racism. Racism interventions. So individual patient level, psychotherapy. Social prescribing. Again, this is something that the UK does much better than U.S. Social prescribing, where we refer patients to community agencies where they can provide support of the kind that we cannot do in our capacity as healthcare providers. At the public health level, we should advocate for policies that will help dismantle structural racism such as with the criminal justice system. This is actually an interesting program that I read about more recently, and I thought that was really fascinating as a role model to follow. Let me just talk about this. So this is called Speak Out Against Racism, or SOAR program. It's a school-based program, but includes the whole of the school, including students, teachers, administrators, staff, everybody's involved in that. So multi-level, multi-strategy program to promote effective bystander responses to racism in primary school. In the sense, there is some racist person who does something bad to a minority person. Other people are watching. What is their response? What should they do? And again, you know, these cases have become apparent in the U.S. recently with some of the murders that occurred. So the goal is to improve the bystander response, to improve peer social norm, and improve school climate regarding racism. And again, this is an ongoing study, so they have some preliminary results, quantitative and qualitative. So quantitative results showed that there's improvement in the students' pro-social skills and teachers' interracial climate. Qualitative results showed improvement in teachers' attitudes and behaviors toward racism, and students' interpersonal racial discrimination, knowledge of proactive bystander response, and confidence and self-efficacy to intervene to address racism. Something like that we need to think about at the societal level. What they did at school, maybe that can be done at a job, or in a college, or some other community organization we may have, that we include all the components of that, and then we have some discussion about that, and then we measure the success. I think it's important to measure it quantitatively as well as qualitatively. So I talked about wisdom as an antidote to loneliness, but can we really enhance wisdom? And the answer is yes. Actually, most of the traits are only partly inherited, 35 to 55 percent, that means most of the trait is not inherited and can be affected by environment and behavior. And wisdom, we know, can increase with aging, experience, learning, but also is reduced by brain trauma and brain disease like frontotemporal dementia. So we can increase wisdom. It's not like IQ. IQ is hard to increase. Wisdom is easier to change. How can we do that? Today, the only thing we can do is psychosocial behavior. I do think that in the future, we'll have pharmacological, biological, and technological means. We don't have them now, but in the future we will. So is there evidence that wisdom can be increased? We published a meta-analysis in JAMA Psychiatry, 57 randomized controlled trials that sought to enhance a specific component of wisdom. One of the three components. One was empathy, compassion, altruism, prosocial behavior. One was emotional regulation, and one was spirituality. These are studies done in people with mental illnesses, people with physical illnesses, and people from the general population. 47%, nearly half of the studies, reported significant enhancement of that particular component and significant increase in well-being. So wisdom is modifiable, it is improvable. But what can we do in real life? What can we do? What can we teach our patients, families, and friends? So there's something called three good things. So before going to bed, sometime during the day, think about three good things that happened to us that we did. We helped somebody or somebody helped us. If we do that every day, then really we start getting up in the morning and thinking, what am I going to think about today? Volunteering, meeting people who are different from us. Again, that's something that is sadly lacking today. If you make it a practice to have twice a week, meet people who are different from us, different in skin color, different in national origin, different in religion, and even different in political perspective. Not that we have to convince each other who is right or debate that, that's not the issue. Just try to understand and respect each other. Self-reflection exercise. You know, we all go to the gym or go for a walk. Can we set aside half hour twice a week for just self-reflection? And mindfulness, where when something bad happens, we say, okay, this will change as it has in the past. So this is something I recently came across and I find exceedingly exciting. Psychotherapy is a biological intervention. You know, we know that early life adversities, why they are so bad, because they affect the gene expression. Whether it is prenatal, prenatal, early life trauma, et cetera, but they affect the gene expression which affects the brain changes and that continues and there is nothing we can do. That's what we think. Not true. Some of the recent studies. So this is a study of successful treatment of PTSD in soldiers with trauma-focused psychotherapy. And they found that people who improved, they also showed significant change in DNA methylation, so that's the epigenetics, of 12 differentially methylated regions in the genes. And there are several other studies for psychotherapy in people with depression, borderline personality disorder, anxiety disorders, and so on. Again, this is emerging literature. They don't prove necessarily, but it's really, and what is important is even going beyond epigenetic changes. These epigenetic changes produced by psychotherapy, as with early life trauma, can be permanent. They can be even potentially passed on to the next generation. So something that bad happens in early life, what we worry about is that not only impact the rest of the life of that person, there's nothing we can do. That's what we think. That's not true. So if we have resilience-improving intervention to a person with depression or PTSD or schizophrenia at the age of 35, according to this, it may reverse the effects of what happened in early childhood. Again, you know, right now this is all speculation. We need a lot of empirical literature to support that. Nonetheless, there is enough exciting evidence to say that something like that is feasible. There's a great paper, a report that came out from the National Academy of Sciences just a couple of months ago. They called it Achieving Whole Health. Whole health is physical, behavioral, spiritual, and socioeconomic well-being defined by individuals, families, and communities. Whole health care is interprofessional, team-based approach, anchored in trusted relationship. Again, I think increasingly in the future, the health care has to be interprofessional. Eight billion people in the world, the number of physicians and even nurses and pharmacists is too small to take care of so many people. It's got to be team approach. So long as it aligns with a person's life mission, aspiration, and purpose. And this is also something I like. When we talk about health care, we talk about well-being of the patients and their families. The well-being of the health care team is also important. And we really must take that into account because there have been reports of increasing burnout among physicians, again, not just nurses, social workers, and so on. And people are leaving professions because of the burnout. So we need to focus actually on the team, health care team's well-being. So I'm coming to the end of my talk. Societal wisdom. So I talk about individual wisdom, but I do think, again, just like there is loneliness individual level and societal level, depression, individual, societal, right? Similarly wisdom, individual level, as well as at the societal level. And that if individual wisdom is an antidote for loneliness, societal wisdom could be an antidote for societal racism. Again, this is all hypothesis, may or may not be true. But we need to think on that line. We need to find out, we don't need vaccines only for COVID. We also need vaccines for this social problem that we have had. And those vaccines will be also behavioral. So how can we increase societal wisdom? At the educational level. You know, right now, the only focus in education is on hard skills. What grades does the student get? What high school? That's the only important. Not in any sports, only the champion is what matters. Everybody else is... I think that should change, just like there's a sportsmanship award in some places. So similarly we should assess, teach and reward soft skills of wisdom, like compassion, self-reflection, acceptance of diverse perspectives to students, businesses and politicians, and not just their academic grades and how much money they make in a job. Same in healthcare. We should assess, promote and reimburse healthcare based on positive psychiatry. The only thing we assess are risk factors. The only thing we assess are symptoms, what is wrong with the patient. We don't ask them about their strength. We don't try to increase their resilience. And that is because we are not reimbursed to do that. So really it's not at our level, it needs to be at the higher policy level. So just the last couple of slides. But again the good news is that I think things are happening. There's something called Compassionate Communities Movement, started in New Zealand, now in Europe, hopefully will come to the US. So what happens is here, the government, local governments, businesses, academic, they all get together to decide to focus on some group that is suffering most in their community and how to help them, volunteering, etc. So take time to help them, advocate for their services and resources, and empower the clients to set personal health code, make community connections. Age-friendly community. The World Health Organization started this movement about 20 years ago. And there are now hundreds of communities in the world where the whole focus is on helping older people. So for example, the traffic light stays green for a longer time when you're crossing the street. When an old person can cross, he takes 20 seconds instead of 10 seconds, right? But it's not just that. It is also allowing older people to have opportunities to learn new things, to participate in community and even to lead societies. There is so much ageism in the society today, especially in the Western societies, that is impacting the well-being of older people. And older people can actually spend their time helping younger generations, which help both the generations, right? Older people will stay healthy because they have things to do, so the healthcare costs will come down. So every which way, the society must focus on keeping older people active and increasing intergenerational activities, right? I mean, that helps older people, that helps younger people, that helps the society. So, in summary, the prevalent vicious cycle of social disintegration, racism, and mental illnesses leading to the social anomaly that I talked about, it needs to be interrupted and replaced with a virtuous cycle of individual and societal wisdom, social connectivity, and greater mental and population-level well-being. If we did that, we can transform today's lonely, distressed, and polarized world into a happier, healthier, and wiser society. Thank you all for your attention. Appreciate that. And... Thank you. Thank you for the wonderful session, Dr. Jesti. We'll take some questions from the audience. Yeah. It would be great if you could, yeah, go there and speak. While you're going, I have a question, if I may. So you talk about loneliness, and I wanted to know more about the impact of social media presenting a narrative, especially with the younger population these days, of an idealized life, and the dissonance between that and reality, especially in marginalized groups that may not have access to it. That's a great question. Social media. So when the social media started, I mean, it really looked great, and the younger people, of course, embraced it. And Facebook, Twitter, and Instagram are now expanding. Younger people spend almost majority of the 24-hour time on social media. But social media have increasingly become more pathological and pathogenic. Number of instances of even suicides have occurred, especially in younger people, especially teenagers, because of the social media. And I think something's got to be done there. Again, that's a tough choice, of course. I mean, there's the freedom of expression, and so on. At the same time, if it is impacting younger people, and it is, younger people today are much worse off than they were 30 years ago. In contrast, older people today are doing better in terms of well-being than they did 30 years ago. That's because of the Medicare, and so on, and the older health care has improved to some extent. Younger people, on the other hand, really are doing much worse, and especially that is affecting the racial minorities, because they're more likely to use social media, and also there is so much racial discrimination in the things that people post on Facebook and Twitter, and also the wrong kind of advice about suicide, and other things. I think there is, it's a major issue that people have neglected. So it is interesting, actually, using COVID as an example. When the COVID started in 2020, all the initial reports about deaths of older people in nursing homes, and so on, from COVID, and it was clear that older people were most susceptible to physical complications. Then the social isolation, masks, and so on, and six-foot distance, et cetera, that was a problem for older people, because they couldn't go. Younger people, it was not a problem, because they had iPhone, and they had social media, so they could communicate with one another easily. They were healthy. So the expectation from psychiatry side was older people will do far worse than younger people in terms of anxiety, depression, and stress. You know what the data show? Data showed that younger people, 18 to 24, did five times worse than people over 65 in terms of anxieties, depression, and stress. This is one paper, actually, we published in JAMA, and another paper that came out in JAMA Network, study of 5,000 Americans across age group. So that really, and that is because although younger people had access to social media, those were unhelpful and pathologic social media, whereas older people, they didn't have social media, but they had good social, good relationship with the few people that they knew. They would call them, talk to them, and that was useful to them. So again, I think social media have become a major social, adverse social determinant of health. I'm sorry, you had a question. Two, actually. One's a kind of picky one. In the optimism studies that you cited, does it distinguish between optimism and hopefulness? So the question is about optimism, the slide I showed, and the question about optimism versus hopefulness, right. Now, clearly, hopefulness is an integral part of optimism. So typically, there are some scales for measuring optimism. And so there are, again, five-item scale, 10-item scales. So typically, they ask questions about the behavior. There's a statement, and you say to what extent they agree or disagree. And one of those statements is hopeful, how hopeful you are. Another question is how happy you feel most of the time. Or sometimes a negative question, like how distressed you feel. And typically, do you expect something bad to happen, being pessimistic. So definitely, hopefulness is a part of optimism. But again, there is strong evidence supporting optimism. Again, nothing is perfect. Too much optimism can be bad. There's no question about that. For example, especially in teenagers, those who are, you know, I'm powerful, I'm strong, et cetera, and they would jump from a running train and they would kill themselves, right. So too much optimism is not useful, but some level of optimism is critical. And again, optimism is a modifiable trait. You can increase optimism. There have been randomized controlled trials in which people have tried to increase optimism and they have succeeded. Again, with psychotherapeutic means, so it means, and not only that, so there are some very nice studies done at Yale, actually, for improving optimism. That increase in optimism was associated with improvement in biomarkers of stress and aging. So it really has a biological effect, too. The other question's been on my mind a lot, and that is, you talked about our polarized society and how you also said how good it is to learn from people that are different from you. Do you have any practical suggestions about how to engage constructively with a group or individuals that have polarized different, especially political, sorts of opinions? I don't know. It is a, this is a very important question from the social perspective, this polarization. But I worry that I don't think there's an immediate solution to that. I think what is happening is, so why there is this loneliness and another pandemic in the last 20, 30 years, I think it is partly because of globalization, partly because of rapid rise of technology and social media, which actually are great in some ways, but they're terrible in other ways. So there's increased competition, and there is 24-7 bad news because of the globalization, right? And that also worsens the polarization, because what it does is, say, I have strong beliefs on one side or whatever side it may be. I select news that supports my views. And so that strengthens my belief. And unfortunately, and again, there's media promote that. That the media succeed by stressing not only sensation of the extremist thing. And so I think, but something needs to be done, clearly, and hopefully it'll happen. Sorry, Subodh, you had it. Thanks, Masterly talk. So my question is really about identity of us as medics and psychiatrists and as clinical scientists, and the way we approach clinical decisions. So I mean, I think you gave us some really good data there about effect sizes and odds ratios of various, both risk factors and also social treatments. And I think most clinicians, well, if not all, hopefully all of them, would not even broke the idea of prescribing three times a dose of, say, lithium to a patient and sending them home. You know, I think it would generate some kind of a disciplinary action in most health systems. And yet, I think we routinely send away people in very poor housing, knowing that that is gonna worsen their outcomes quite significantly. So I think it's the act of commission versus act of omission. I think we, so when you talk about social prescriptions, I think it's the omission that is a significant factor, right, I mean, and because we routinely don't intervene with smoking cessation, for example, knowing that that has a very large effect size in terms of reducing mortality. Health systems are not designed to kind of reduce that. So where do you see that? And how do we address that thing? I mean, about this, our clinical decision making and how does that influence, how is that influenced by what we see as acts of omission versus acts of commission? So the question is about social perception. Is that right? Yeah, I think this is, that's a very good question. And this is something we need to understand. And there is no simple answer, of course. Things are affected and multiple perspectives. But what I see a problem that we really need to look at the science, we need to develop the science and then we need to have reliable, valid and practical ways of assessing these things. And right now we don't have them. But even if we had them, again, in the UK, the UK system is better than the US system. Here it is so broken, I mean, it really, hopefully it'll get better. I think there's no question it has to get better in order to do that. But in terms of health inequities, it is much more here than in some other parts of the world. I think what, so from the US perspective, what I'm thinking about is we need to develop some assessment that are practical and valid. We need to have more of a team approach. And again, the social prescribing is a really good way of trying that out here. And so the more we learn from each other, I think the more useful it will be. So really there's even more need for international collaboration and the global. Thank you very much for your presentation, really. Thank you very much. I guess my question is a little bit was about, in our political system sometimes there are people who are very hurtful in what they say, disrespectful what they say, sort of hate speech almost and being prejudicial. So I'm just wondering sort of what the first person mentioned too is if you could talk a little bit about how words, it's hard to sort of, it seems like it's a big fight against a, it's a very difficult topic to bring up on how to counteract that and how to get that sort of in a political realm. I guess I was wondering a little bit because to be open-minded on all different people's views, but also when people do speak in such a narrow-minded way that it's very hurtful and obviously it doesn't help with health. So it's a difficult topic. No, again, that's a very nice, important question. And so keeping an open mind is important. Acceptance of diverse perspectives is important. And yet, there's a limit to whatever we, everything has limits. The good things also have limits. As I said, optimism has limits, et cetera, et cetera. And accepting diversity of perspectives again also has limits. I mean, we won't accept murders or rapes or things like that. No, I mean, that's not an option. But there are things where people have differences of opinion and if they're rational differences, I think we should clearly understand and try to do that. I think what happens is we tend to, I mean, it is like in the old, still there are some religious wars, but there are many more religious wars in the old days, right? When millions of people actually were killed in religious wars because they believed that my religion is the only right religion. Somebody else's religion is wrong, et cetera. Today, it is more sort of more national level, but within the national level, then there are political, more on the right, more on the left, things like that. And this is actually all over the world, not just in the U.S. And so in the sense, some who are more liberal, some who are more conservative, and it doesn't mean that one is right and one is wrong except when they go to extremes. Again, going to extremes is really, should not be allowed, and that should not be acceptable. But to answer your question in a different way, it is like we think about something is good or bad, but something can be both good and bad, and something may be neither good nor bad. And we need to have those options open and not come to a definitive conclusion all the time quickly, is the same. So again, so we need to have open mind, but not totally open mind. And clearly, some things are not allowed. Again, as I said, murders, rapes, et cetera, I mean, that's out of question. But there are other things where they're clearly, I mean, you can see that in the U.S., abortion, for example, I mean, those are tough issues to talk about. But I think there should be, again, dialogue that is needed, yes. Thank you very much, and one very quick thing. My wife went to a seminar on diversity. She's Caucasian, and everyone who spoke was people of color. And what they said is the new way to discuss it is people of color are actually in the global majority. So instead of, she was saying that the new speaking is instead of minorities, sort of people of color are global majority. Thought it was a very interesting switch, you know? Good point, thank you. We have time for another one to two more questions. Thank you so much for your work, and for this talk. Promoting, I think, very pro-social and compassionate and related values. So I'm just curious, why do you think this is such a hard question? Because obviously we're at this tipping point or this inflection point between hierarchical dominating abusive systems of power around the world, and more what I consider wise. So I'm just curious, what's your take on that based on your experience of these things? My sense is it's not that people are bad, or society is getting bad. I really think globalization and very rapid rise in technology have changed things so fast, we don't know what to do with that. Even biologically, I don't know, some people thought that the brain is not capable of actually adjusting so quickly. And the technology, by the time I bought my iPhone 12, they already had iPhone 15 out there, and then other things. How things have changed in such a short time. I mean, right? And we don't know how to handle that. And again, these are both good things, but on the other hand, globalization has increased competition. It is exposing us to 24-7 bad news, because that's the only thing media publish. And the whole world, there is something bad happening someplace. And that's all that is the main news, is some terrorist attack here, war there, earthquake there. So all that we hear is something bad, and that affects our... So it is a social anomaly, I think, really that is affecting our health. And Gallup Poll does surveys every year of feeling of anxiety, stress, depression. They found something like 25-40% increase in anger, hatred, anxiety, depression in the US in over a 12-year period. So I think this is something genuine that is happening because of these changes. And I think what is needed is really thinking at a high level, and sort of what can we do, what is feasible. Whatever we decide is... We can't ban social media, right? So how do we control that? So again, these are things, there is no quick solution. But I think what is needed is at least discussion. How do we do something? And all solutions will not work. So preventing our kids from having, you know, not using iPhone for more than an hour, it's not going to work, right? So what do we do? I mean, obviously, I don't... But we need to bring together people with different perspectives, and then come with some conclusions. I think that's where we can do something. I would say an overwhelmed person with a gun is much worse than an overwhelmed person with an iPhone. So maybe that's some place we could start. One more question. Thank you for the excellent talk. And in recent years, there's been exponential growth in the field of peer support, which we know is evidence-based, people utilizing their own lived experience in recovery to help others. Within that field, there's been a struggle to identify what exactly it is about peer support that is so impactful. And your talk sparked me thinking perhaps the word for that is wisdom, imparting wisdom. I wonder if you have thoughts about that. Thank you. Again, I think probably wisdom is... It's the principle behind that that matters. So if we can promote those things instead of what is being promoted right now, that will be helpful. But I agree, peer support is critical, and that's the social connections. That actually, compassionate social connections is what matters. Thank you very much. APPLAUSE

Dilip Jesti

psychiatry

social determinants

mental health

racial discrimination

social anomie

loneliness

behavioral pandemic

wisdom

empathy

resilience

anti-racist policies