Good afternoon, my name is Monica Taylor-Desir, and it is my honor to share this next hour with you, discussing health disparities and bipolar disorder. We'll look at treatment, research, and community engagement. I am an assistant professor at Mayo Clinic in Rochester, Minnesota, and I'm also the Associate Program Director for the General Psychiatry Residency Program. I am a fellowship-trained community psychiatrist, so most of my clinical practice is doing assertive community treatment in Olmstead County. I also co-chair Equity, Inclusion, and Diversity for our department, and my research interests include disparities in bipolar disorder in the African-American community. During this presentation, I will use the words Black and African-American interchangeably. So, I just want to say thank you to the grant funding that is supporting this Striving for Excellence series, and this is made possible by a grant from SAMHSA and the U.S. Department of Health and Human Services. So, today I would like to share with you the work of my colleagues and researchers that have gone before me, and the work that we have done together with colleagues, and how we can move our field forward towards more equitable health care. So, our objectives for today are to identify current treatment disparities for bipolar disorder in the Black population, identify motivating and discouraging factors for participation in research in the Black population, and identify resources and opportunities to build an effective roadmap for change. So, let's start at the very beginning. When I say the words bipolar disorder, think about what you've heard about bipolar disorder. Was it even spoken about in the communities where you grew up or where you live? And what are the words that are associated with bipolar disorder now? So, bipolar disorder is a complex illness with a heritability estimated to be approximately 85%. And Black African-American individuals with bipolar disorder have significantly higher incidences of receiving initial clinical diagnoses other than bipolar disorder. So, when we think about, are we even talking about bipolar disorder in the Black community, think about who can you identify as a person in the media who has talked about having bipolar disorder. The actress Jennifer Lewis has now started to talk more about her struggles with bipolar disorder, and she has said that it is easier to speak about bipolar disorder on stage than within the Black community. But if you think about the National Minority Mental Health Month, how did that even come about? That came about from the advocacy of Bebe Moore Campbell, who had a daughter that had bipolar disorder, and she was struggling with finding resources for her daughter. Even though we talk a lot about National Minority Mental Health Month or BIPOC Month, Mental Health Month, we don't really recognize that this was something that started because of a person suffering with bipolar disorder in the African-American community. So, our misdiagnoses are often schizophrenia or major depressive disorder. And there's been an extensive history of misdiagnoses with studies reaching back to the 1970s. So, as early as 1983, there was a med record review that looked at the misdiagnosis of 76 patients with bipolar disorder that were in an inner-city clinic in New York City. Most of the Black and Hispanic individuals with bipolar disorder were previously misdiagnosed with schizophrenia compared to White individuals. And in 2004, there was also a study looking at relationships between ethnicity, symptoms, presentation, and diagnosis. And within that study, the African-American participants were four times as likely to have a schizophrenia diagnosis than a bipolar diagnosis. So, just to make sure we're all on the same page, we're looking at an illness that has manic symptoms and at times can have depressive symptoms. The manic symptoms, according to the DSM-4, or excuse me, that shows my age, DSM-5TR includes manic symptoms, the decreased need for sleep, increased or faster speech, having uncontrollable racing thoughts, having distractibility, having increased goal-directed activity, thinking you can do four or five projects at one time, and increased risky or impulsive behavior that is often seen as increased sexuality, increased precocious behavior, speeding down a highway, sometimes doing activities that end up having legal consequences, or winding up needing a hospitalization, and this needs to last for at least one week. So most of the time, we will be focusing on bipolar I disorder. Our depressive symptoms include feelings of worthlessness or guilt, fatigue, increased or decreased sleep, increased or decreased appetite, having some restlessness or slowed speech or movement, can have difficulty concentrating, and also you can have suicidal thoughts or frequent thoughts of death. And either within the manic symptoms or the depressive symptoms, we can see increased in suicide attempts. So we see that there are misdiagnoses. So is there really a difference in symptom presentation for bipolar disorder between persons of African ancestry and persons of European ancestry? So in this study done by Lee and colleagues, there was a meta-analysis of over 4,000 patients with bipolar I disorder. So Black patients were about 775 persons within this study, and what they saw in this study, which was two large-scale collections, the persons who self-identified as being Black experienced persecutory hallucinations and persecutory and mood incongruent delusions at a higher likelihood than those patients that self-identified as White. There were fewer prototypical manic symptoms, so instead of having elevated mood, they were often seen as being more irritable or more dysphoric. They also had a higher rate of decreased appetite and weight loss and an increased endorsement of sleep difficulties. And sleep symptoms are important when we're looking at bipolar disorder because this symptom is less likely to be affected by provider interpretation and bias. And sleep difficulties have been linked to increased adverse metabolic effects, cardiovascular effects, and poor cognitive outcomes. Reversed sleep and disrupted circadian function is also a likely risk factor for illness recurrence and poor outcomes. So we see that there's a multifaceted and complex reasons for persons to be misdiagnosed, but we also need to think about the adverse risk factors of our patients that are marginalized and the inequities that exist even in attempting to get care. So what is the impact of diagnostic delay? Well, if you're presenting later for care and you are also presenting with more severe illness symptoms, you'll see an increased illness regression. There is less likelihood of responding to lithium, which is a gold standard treatment for bipolar disorder, and delays in seeking treatment may impact presenting symptoms of mania and the treatment selection. We also see that there is a presentation of high psychotic symptoms, lower rates of mood symptoms, again, which lead to misdiagnosis of a psychotic disorder such as schizophrenia. So I'd like to present to you a study that my colleagues and I did on the data of bipolar biobank of enrollees of African ancestry. So Mayo Clinic has a bipolar biobank, and I had the opportunity with my colleagues to take a look at some of the demographics. So what we looked at were 1,895 enrollees of the bipolar biobank, but we also combined the data in Rochester, Minnesota, with biobank collections from Lindner Center of Hope in Cincinnati, Ohio, the University of Minnesota, Minneapolis, Minnesota. And out of those, 65 participants identified as having African ancestry. So that is about 3.5%. And to our knowledge, these data are the first to show clinical differences in comorbidity patterns, current treatments, and treatment outcomes. So looking at this demographic, we see that there's only 3.5% of our enrollees identified as having African ancestry or being black. This is a small percentage, but this is consistent with other work looking at minoritized populations, enrollment, and genetic studies. And what happens is if there's a low participation, there may be bias and implications looking at the outcomes of genetic studies and looking at risk. So minoritized persons who participate in studies, often their samples are excluded from the initial analysis to reduce heterogeneity and chances of confounding. And we need to make sure that we are coming back and using those biological samples for the data that was initially gathered. So in our particular study, we looked at demographics, and those of African ancestry were less likely to be married, less likely to have a full-time employment, and less likely to have achieved a bachelor's degree. But what we saw in terms of similarities were that rate of psychosis was the same, there was no significant difference, the rate of suicide attempts in this particular set of data was similar, the rates of anxiety was similar, and the rates of substance use comorbidities in general were similar. Also, the use of antipsychotic drug use at the time of entry was similar. But we did note some significant differences, including a history of PTSD was higher in those of African ancestry. We also saw that tardive dyskinesia was higher in persons of African ancestry, there was lower history of lithium use, and lower history of mood stabilizers. So when we look at this, we're wondering like, what is more, what are these differences related to? In terms of the history of PTSD, we can think of our social determinants, health, racial trauma, and racism within society. When we look at the increase of tardive dyskinesia, and why is that important? Well, Black individuals are two times as likely to develop tardive dyskinesia as white patients, and they're more likely to have genetic variations that slow the metabolism of antipsychotic medications, which can make them more sensitive to dose and duration of antipsychotic medications, which can lead to an increase in their likelihood of experiencing this chronic condition of tardive dyskinesia. Tardive dyskinesia also leads to poorer hospital outcomes, so it's important that we can minimize the incidence of developing this condition, and this condition is more likely to be developed if they are getting antipsychotic medications. So again, what we see is there's less lithium use, which is a gold standard, and there's less use of mood stabilizers. So if we see later presentations or we're seeing misdiagnosis of African-American persons with bipolar disorder, we also see that they are experiencing less gold standard care and more risk of side effects with medications. So when we really look at other studies looking at treatment disparity, there is a study of 415 African-American patients with bipolar disorder, African ancestry patients with bipolar disorder, and 480 with European ancestry. And again, this study shows, which was published in 2020, that there were high rates of first-generation antipsychotic use in those of African ancestry, even when they controlled for a psychiatric diagnosis, even when controlling for a neurological diagnosis, treatment settings such as outpatient clinics, inpatient hospitalization, metabolic factors, and other socioeconomic factors and social determinants of health. Again, there's significantly less use of lithium, and they showed significantly less use of any mood stabilizers. So going back to the low participation rate, let's look at research disparities. So we know that African ancestry participants and those of Latinx and Hispanic ancestry represent 3% of genome-wide analysis studies, and the underrepresentation of African-American patients is very complex. We know that there is a mistrust of research when we look at history of the Tuskegee experiment and also Henrietta Lacks and Johns Hopkins community. Again, we see frequent exclusion of samples to prevent misanalysis, even though they have been recruited into a study and they've given a biological sample. There's also concerns of exploitation and concerns about investigator motives, and there's concerns about access to data and privacy. So if we could get identification of genetic risk factors associated with bipolar disorder, this would add value to early diagnostic and clinical staging paradigms, and this could provide greater precision to interventional strategies. So in general, what are the attitudes and perceptions about participating in research? The Depression Bipolar Support Alliance, in collaboration with Mayo Clinic, completed a national web-based survey to assess just the interest of persons participating in a biobank. They looked at 385 persons and people said, you know, I would participate—and this is population in general—if it was a funding source that was not related to the government, or I would participate if someone gave a professional opinion that I would participate, such as the doctor told me I should participate. Mental health consumer opinion, I might participate if I know that there's someone in my family or it is important for me to participate as a person with lived experience, and 91 percent said they would participate, especially if they could get a return of the research results. But when we're looking at research disparity, and we know that there's only about 3.5 percent of persons in marginalized communities that participate in research, let's take what are some of the reasons that persons in those communities may participate in studies. So my colleague Eric Fallender at the University of Mississippi Medical Center did a study in 2019 looking at 63 participants with a purpose of understanding attitudes and driving factors that would influence consideration of research participation, particularly of bipolar patients in a predominantly Black African-American community. So this was in Jackson, Mississippi. So what he found were that Black African-American participants expressed greater concern compared to White participants in having a violation of their trust. They wanted to make sure their privacy was protected, and they also wanted to make sure that they still had some autonomy in dealing with the medical community, but still they were willing to participate in a bipolar biobank. And what drove their desire to participate was having elevated levels of benefits of participation that did not exist. So for example, I will use myself, and an opportunity to participate in an aging study at my institution, and we go through the consent, and I am well-versed in research and consent and the history, go through the consent, go through family history, and even though it says there's no benefit health-wise, I am still hoping that when they do a MRI of my brain, look for aging, or if they do a PET scan, that I would be able to see that. That is a benefit to me, but that benefit does not exist. And I even asked the question after I signed all the forms, like, do I get to see this in my record? And I'm like, no, you know, it already says the benefit doesn't exist. So I think it's difficult to communicate what the benefits are of participating in research to the community, and making sure that people do not overpromise what an institution can do for a community. So there needs to be education of benefits and clarifying the therapeutic misconception. So those that did not want to participate in studies did not show increase in concern, but showed decreased motivating factors. There was nothing that was really motivating them to participate. For example, when we go back and we look at why people would not participate, violations of trust, privacy, autonomy, that apprehension has extended to participation and genetic biobanking, even outside of mental health studies. Again, they showed fear of exploitation, a distrust of researchers, and not having protection of their personal data and access to privacy. And then should we look at positive aspects of participation? So there was an elevated level, again, of benefits that did not exist, and about 50% of people will participate in some type of research because they say there is some personal benefit, and about 25% will participate because my doctor asked. So we also looked at not only what motivates people to participate in studies, but also what motivates people to participate as a community advisory board member. So if we are moving this whole field forward and looking for more inclusivity in research and studies, we also have to have a seat at the table talking to researchers. And Mayo Clinic had a partnership with University of Mississippi Medical Center. We looked at the community advisory board, which was made up of 12 females, 3 males, 4 white persons, 11 Black African-American persons, and it included people with lived experience, patient advocates, resource providers, and clinical providers. And really, they were serving to look at what is the capacity for research projects in the community. These community members expressed concerns related to negative effects of participating in research. For example, people may not participate because they have a concern about its impact on employment or insurance or stigma and racial discrimination. They also talked about the importance of research and the importance of participating and having the community have a say in the development of research. But they also expressed the need for education about bipolar disorder and education on genetic research. So, what I would say is, how can I volunteer for a research study if I do not even understand the disease? Or how can I volunteer for a research study, excuse me, if I don't understand the process or the genetic research that's happening? So, we use a community engagement approach, which is a structured approach for obtaining input from stakeholders. It really helps to enhance the research design, develops input of conduction of the research, and also helps in dissemination of research results. So, what we wanted to do was identify the benefits and barriers to participating in a bipolar biobank community advisory board. And there were five stakeholders that participated in this, and we wanted to look at the willingness of Jackson residents to participate, the willingness of minoritized residents to participate in a community advisory board, and the willingness of Jackson residents with lived experience to participate. And what we found was that, in general, persons thought that serving on a community advisory board for research would provide positive impact on the community. It would be also an opportunity for collaboration and networking. And what we found, we had a challenge of COVID-19. So, as the world went upside down, first, we were doing all of this in person, and we were going down and meeting with folks in Jackson, Mississippi. And then, as with everything, we needed to change to virtual meeting. And there was a challenge of continued engagement when everything was virtual from a supporting institution that was hundreds of miles away. Persons thought that if they served on the community advisory board, that they could really look at changing the history of minoritized populations in research. How could we make it better for persons and their experience in research? This was also an opportunity for health education. We brought in lots of our researchers to do presentations at each of our board meetings, and persons were interested in having influence on the research process. They also wanted to make sure that there was representation, and some persons also said that it was important to have those financial incentives. So, again, you're making sure that you're asking people to come, you're looking for their experience, you're looking for their wisdom, and they need to be compensated for their time and their travel. And, you know, if it's over a dinner hour, making sure that there's food and beverage and people are comfortable when they're attending meetings. But we also looked at what are some of the barriers to serving on a community advisory board. And a lot of people said it was the time commitment, which is something that we had looked at before. All of us have very busy lives and time commitments with family, and some of us are caregivers. And it can be a huge time commitment to serving on a community advisory board, especially as studies are getting set up. Sometimes the barrier is just being available. What is the location? So, even though we switch from meeting at the university to going virtual, so people can meet at any time, it was still difficult if it wasn't an easy location for people. And sometimes people thought that doing it virtually was not as easy as doing it in person, at least not as focused. And then people also talked about feeling intimidated. So I talk a lot with folks about having an authentic partnership. People with lived experience, sometimes people in community organizations will often feel some type of intimidation meeting with academic institution researchers. So when we talk about what authentic partnership is, we often look at what is your willingness, if you are the researcher from the institution, to share power? Or what is your willingness to give away power? And this is huge, because when you're partnering with communities, definitely there needs to be a leveling of the playing field in order to really hear what community needs are, and to have an investment from the community. I often talk about it takes time to build those relationships, and a person needs to be available for the community partners. And then also, there is the tendency, again, to overpromise when you are representing an institution to a community, especially if you're young and passionate, and you want to do everything, speaking from experience, to overpromise what the institution might bring. Another barrier is transportation. So really thinking about how to get people to the meeting. And the other barrier was not really knowing what the intention of the researchers were. So being able to communicate honestly and clearly what the research goals are, and what the research benefits are. And then again, people are often concerned about confidentiality and stigma. So we look at what can we do with our next steps. So we look at thinking about the need for larger studies in our communities, and making sure that we are including everyone, and also that we are able to use everyone's contribution. Whether that is serving on a community advisory board, or whether that is making sure that we're using all of our biological specimens within the analysis, and also making sure that we have good return back to our communities. So we need to look at collaboration with communities, with researchers, and with persons with lived experience. And for this one, we can think of some of the organizations that are in your community that looks at persons with lived experience. So I've worked with Depression Bipolar Support Alliance, and they have developed online support groups. And this was right after the pandemic. This was online support groups for various marginalized communities and racial ethnic communities, but they do have one for black persons living with depression and bipolar disorder. And this has been one of their most successful support groups. And so just as of 2023, I'm sharing this from Kimberly King, who is the Mental Health Equity and External Partnerships Senior Management for Depression Bipolar Support Alliance. Until 2023, there were 403 black support groups, and that over the year, they had over 6,000 attendance slots. So that means that not definitely 6,000 people, but there were attendance of 6,000 times, we'll say that. And there were even 34 groups per month online that the black community could participate in. And then just doing a survey of persons who attended, they showed that 97% of them felt welcome in an online community, 92% were more hopeful after attending a peer support group, and 87% learned new strategies after each group. So this is a wealth of information, and these are the people that are the true experts. The persons with lived experience, that know their bodies, that know their experience, and can communicate with researchers what they're looking for, and communicate with communities their need for new opportunities. We need to look for improved understanding of health disparities. So that means identification of biomarkers, so this is at the genetic level, looking at genetic variants that may show increased response to medications. So, for example, we talked about lithium being less used in the African American population. But there are studies that show that low-dose lithium in those of African ancestry has a greater response, a greater improvement of depressive symptoms than those of European ancestry. And so we look at what makes that difference, what is the genetic variant that makes that difference, what are the environmental factors that are important for distinguishing risk so we can move away from race categories. And then the other thing is definitely developing ethical guidelines for the recruitment of patients in minoritized communities. How do we get persons more involved in research so that when we look at studies, we know that they have participants from the Black community, that the results apply to the Black community, and we can trust in what the researchers and the studies are saying. So a lot of times, you know, sometimes we'll say, well, this medication is shown to be great, but most of the population that were in the studies were usually white men. And so we need to be able to have studies that are from our own community. So these are the next steps that we're looking at. I would like to take this time to thank my team, which spans from Mayo Clinic to Wash U in St. Louis to the Lindner Center of Hope in Cincinnati, Ohio, and to the University of Mississippi Medical Center. So at this time, I am open for questions. And I see, let's see, are there any in the chat? Okay. Thank you so much for your presentation, Dr. Taylor-Desir. That was fantastic. So one question that I was thinking about as you were presenting was, how would you recommend someone go about finding a provider for bipolar disorder? What would be kind of steps that an individual could take to find the right fit, given all of this research that you've conducted? Thanks, that's a really good question. So one thing that we talk about is initially if you're having difficulty with your mental health, you're thinking something's going on, maybe you're thinking, maybe I'm bipolar. First, we say, talk to your primary care provider first, say, hey, there's something that's going on. Can we talk about this? These are my symptoms or I haven't had an opportunity to really sleep well, or I feel like my mind is racing. And I say, start with your primary care provider because if we always say, start with your psychiatrist, we know that it is tough to get in to see a psychiatrist and sometimes there's a long wait. So first we say, start with your primary care provider, they can help you in assessing symptoms, they can also help in placing referrals that are appropriate. But also, you can also start looking at community support groups, not only Depression Bipolar Support Alliance, but when I talked about earlier, B.B. Moore Campbell really was instrumental in developing appropriate community-based groups through NAMI, so NAMI is a good one also. And if you're in crisis, no matter what it is, you can always call 988. Fantastic, thank you. And just another kind of more broad question, but what current research are you doing? What upcoming presentations do you have and what are you working on within this field currently? Thanks for the question. So right now I'm doing some pretty exciting work with the National Network of Depression Centers and some of my colleagues at Mayo Clinic and looking at statistics on their mood outcomes program. So really that's programs across multiple institutions that look to standardized treatment for depression, for bipolar disorder. And we've been able to look at a set of over 40,000 patients and really began to look at what are the racial ethnic differences in outcomes in terms of diagnosis, depression and bipolar disorder, looking at suicidal ideation and suicide attempt. Also, we are looking at what are the differences in the lengths of treatment and how long people stay in treatment? How many follow-ups do they get? I think a lot of times what we see, especially, for example, when we're looking at our disparities in lithium, some of the biases from providers can be, well, they're not gonna stay. They're not gonna come back. Meaning our African-American patients aren't coming back. They have difficulty getting to the clinic. How do I know they're gonna get labs? So we're really trying to look at, is there really a difference in length of treatment? So those are some of the things that we're looking at and hoping to present in upcoming conferences. And also doing some work looking at a review of racial and ethnic disparities in depression care. So looking at children and adolescents, looking at postpartum depression and racial ethnic disparities there. And then across the lifespan, even to late life depression. So those are some of the things that I'm looking at and would love to have any questions from people or any questions related to, oh, sorry. Any questions related to just anything in the presentation or current treatment practices for bipolar disorder? While we're giving people a minute to post their thoughts and questions in the Q&A tab at the bottom of their screen, I just have one more question. Going back to kind of the individual level. So going back to my first question surrounding individuals seeking care, what would you recommend for someone who has viewed your presentation and is now considering becoming a research participant? Oh, I'm sorry. Can you repeat that for me? So sorry. So what would you recommend for someone who has viewed your presentation and is considering becoming a research participant? So for, again, for research participants, first, I think it's absolutely wonderful even if you're thinking about participating, but it can also be really anxiety provoking because there's usually not always a good, clear outcome initially. So you may feel like, oh, I wanna participate, but if you are associated with a academic center, there are always a lot of research programs that are going on at that time. So if you are affiliated with a university or a clinic that's affiliated with a university, and let's say you are interested in participating in research for mental health, you could ask your provider, you could often go onto the website for that clinic or for that university, and there usually will have a list of studies that are ongoing. If sometimes if you're participating in a community organization, for example, NAMI or Depression Bipolar Support Alliance, sometimes researchers will like to partner with persons that are participating in there, and you could do that. And then when you are getting to the research, I say, first, always read everything. And if you are a person that is considering doing something with a biological specimen, now we have so much more technology that things can live in perpetuity. You could be dead and gone and your DNA is still there. So you wanna make sure that you understand what that means when you are donating a biological sample, how long it's gonna last, what are the rules for like destroying the sample or getting rid of the sample. I used to work with tribal communities, so sometimes it was really important to have a biological sample returned. Those are important questions. And then talk with your family about what it means for you to participate, because it could impact generations in a positive way, but you wanna make sure that it's not a secret that you participated in research and that you totally understand. I think the one thing that is also important is knowing that you can withdraw your participation at any time. It does look like we have a question in the chat. So we have this question that says, what do you recommend for the shared decision-making for the bipolar disorder patients? That is an excellent question. Not a plant, but it was an excellent question. And I like this question because when you talked again a little bit about what are the other studies that we're looking at, there has been a lot of studies on shared decision-making with bipolar disorder and definitely focusing on patients of European descent or white patients. There has not been good studies on what does shared decision-making look like with our patients from marginalized communities and our black patients. So when we talk about shared decision-making, sometimes there are a lot of guidelines like you should do this first. You should try this medicine first. And you know, there'd be pamphlets. You can talk with your provider about the decision tree. I have these concerns or I don't like these side effects. And those are important discussions and you don't have to have like a formalized decision tree. But I also recommend for all types of people that sometimes when you're going in and you're meeting with your physician or your mental health provider, and especially when you're in crisis, if you have a trusted family member or trusted friend that can help provide the history to your provider so they can look at all the symptoms and what's happening and you can help have a better decision-making process. So also if your physician is saying, this is what you need to take, or this is my recommendation, also ask, what are the alternatives or are there other treatments available? Are there treatments that are not medication? What kind of therapies can I participate in? So those are the things that I would recommend for shared decision-making. And I think that's a great question. So if you're a young person or a researcher, resident, start thinking about your research on that. I think that one is really important. I think, go ahead. To just expand on that a little bit more. So talked about kind of the shared decision-making from the patient perspective, but from the provider perspective, keeping in mind those disparities, what would be your recommendations from the provider perspective to kind of encourage that shared decision-making for the patient? Yeah, and that's really good. I think also from the provider perspective, we talked a little bit about what is, maybe some of the biases of why we don't choose lithium or why we don't choose a certain medications. So that's one thing to keep in mind, but I think we often have our own biases on what are the treatments that we like? I think this medicine is perfect. I like to prescribe a lot of Bilify because it's low metabolic side effects, or I like to prescribe this medication because it's more sedating. But I think opening up the discussion with the patients and saying, what are you most concerned about? What are the, what have you heard about medications? So even though I've talked throughout this presentation about lithium is a gold standard, lithium is a gold standard, what is the perception of lithium in your community, in your family? People might think, I don't want that medicine. And also just sort of asking, what types of medicines would you be willing to take? What are some of the challenges of taking medicines? And we also look at, can we do a long-acting injectable that will help as a mood stabilizer? So there are a lot of things, definitely from the physician perspective. And I think for those that are in training, those who are in practice, to really not only see the patient, but also think about what are some of the social determinants and what are some of the social factors that are influencing this person's presentations? Fantastic. Well, thank you so much, Dr. Taylor-Desir, and thank you to all of our participants today. We hope you have a fantastic rest of your day. Thank you. Excellent. Thank you so much. I really appreciate it.

health disparities

bipolar disorder

African-American community

misdiagnosis

community psychiatry

genetic research

ethical guidelines

mental health outcomes

social determinants