Welcome everybody. It looks like we've got about 7 people here. So maybe we will give it another moment or 2 to see if anyone wants to join us. Welcome, welcome. We're excited to. I guess. These early slides are. Less content based, so perhaps we can start with that and then hopefully some other people will join us as we continue. That sounds like a plan, get to it. We're here this evening to talk about how we wound up here. And look at racism as the root cause of a lot of our mental health. Funding by this, for this initiative was made possible by grant. Number H7 9 FG 0 0 0 at 9 1 from SAMHSA. And the views expressed in written conference materials or publications and by speakers or moderators do not necessarily reflect. Official policies at the Department of Health and Human Services. Nor does mention the trade names, commercial practices, or organizations imply endorsement by the government. We will be talking about the APA is accredited by to provide education and the APA doesn't. This event for a maximum of 1 category 1. So, you should claim only the credit commenter with the. We'd like to download our handouts in the control panel. You can see there is a. Webinar slide handout, and you can use the page symbol to join where we are. Um, okay. It looks like there is, I'm going to make sure I'm sharing the right window with everybody. All right, how about now? Okay, then here we go. That's how you download and. All right, I like to introduce you. You might want to go. Thank you. Thank you. So presenting with Dr. Laura Cox and as you can see. Her up in the corner, she's not afraid of anything, especially spiders. And I'd like to introduce you to Dr. team March who remains just as skeptical as he was in that lovely baby. We have both clinical assistant professors of child and adolescent psychiatry at and why you and we've worked together as part of the. Of the juvenile justice mental health service. Providing mental health care to you can secure a non nonsecure detention in the city. We've been presenting together on trauma and disruptive behaviors for almost 5 years and more recently, we broadened our scope. Dr. March works for the New York family, and I'll let him tell you a little bit about that. Keep going. You can talk about that. No, we can you can ask me later. Okay, we have no financial conflicts of interest. We disclose and excellent conflict resolution skills. So, just a quick outline of the topic, we will get started. Talk about why we should be thinking about it implicit bias. The R word put some things in context and look at our practice. And then the words we use in our package. So, let's get started. So, when we say we're not experts, we mean, our expertise comes mainly from experience and what we've seen in our own practices and that of others. And because we're not be claiming to be experts, we would like input from everyone. We want this to be an engaging, ongoing conversation. And it may be an uncomfortable conversation and that's okay. It's not only okay, actually, it probably should be uncomfortable because if you're comfortable with the kind of status quo that we're describing, that's a problem. But if it's the wrong kind of uncomfortable, please feel free to interrupt it. So, the social determinants of health are how we are taught about racial and ethnic disparities in prevalence, intervention and outcomes. Sometimes, but not often, we're taught a little bit about the concept of systemic racism, maybe a teensy bit about implicit bias. But these are the contexts in which racism is usually discussed in medical education. It's external, it's abstract, it's not connected to doctors and their decisions, and it's definitely not connected to us as individuals. What we're not taught is ideas like race is not a risk factor for disease. Racism causes worse health care, education, policing, et cetera, and that causes disease. Thank you. Can you please stop? Sorry, I'm asking you to stop. Please don't come close to me. Sir, I'm asking you to stop. Please don't come close to me. Please make your phone off. Please don't come close to me. I'm taking a phone call. Please call the cops. Please call the cops. I want to tell them there's an African American man threatening my life. Please tell them whatever you like. Excuse me? I'm sorry? There's a African American man attacking my mom, he's trying to rape me, and eyelid me, and my dog. As an African American man, I press myself and my dog. I'm sorry, I can't hear you, I'm being threatened by a man, he's trying to fuck me, I can't move, I can't move. Thank you. A little intense. So check out the rest of the headlines on the slide, they were all from the last week of May 2020. That's right. What a week that was. And up until this point now, you know, we see similar kinds of events, like it's still an ongoing issue. So that Amy Cooper, who was featured in the video, actually faced up to a year in jail time for filing a false police report. As of February in 2021, this year, charges were dropped after she completed a five-session educational and therapeutic program focused on racial identity. She also is making a lawsuit to try to get her job back or some sort of compensation. So let's take a step back in time to something perhaps a little more subtle. This classic peanut scene with the series' first Black character, Franklin, is in some ways a good example of implicit bias. How many of you noticed the seating arrangement? The increase in diversity made some people happy and others upset, while some had mixed feelings. Happy, Franklin is there, but wonder why Thanksgiving has to be segregated. This idea is related to our own perceptions of ourselves. In a study published last year in the Journal of Social Psychology, 100 college students from a Southwestern university were asked to rate the racism of their own behaviors. Initially, right after creating their own list, and then again months later, under the assumption it belonged to someone else. The majority of the behaviors rated were more racist when the person, when the individuals thought it was someone else that actually did the behaviors. This helps explain the disconnect between feelings that we have and our own behavior, because we all like to think we're exempt when, you know, clearly many, many things are happening. So, first thought, when you look at this slide, I want you to hold on to those, what about this one? So why should we be thinking about this? Well, remember those first thoughts. In a society that claims to be colorblind, and a profession that prides itself on both those benefits and non-maleficence, race matters. It matters for rates of specific diagnoses, it matters for treatment decisions, it matters for clinical outcomes, and on a more micro level, it matters for each of our interactions with every patient that we see every day. So bias directly influences physicians' decision-making. The higher a physician's level of bias, the greater the differences in the treatment choices for patients. When studied, we see this phenomenon regardless of specialty, clinical setting, and patient age. This is true for appendicitis and long bone fractures in both adults and kids. When physicians are faced with higher time pressures, they are much more likely to make a less serious diagnosis for a Black or Latinx patient with chest pain, and less likely to refer them to a cardiologist. Of note, there was one study that measured implicit bias at the beginning and the end of a shift, a stressful ER shift that found that, as you can imagine, much more bias towards the end of the shift than when it started. And when it comes to patient outcomes, I can speak about this from personal experience. I've seen an issue from both sides as a patient and a provider. Anecdotally speaking, in reference to people I know, almost every Black person has had a bad experience with the healthcare system. As a relative of patients, I've seen people suffer unnecessarily through suboptimal care or just avoiding care completely. As a provider, I've heard many colleagues talk about noncompliance, and it rubs me the wrong way. I've been present during patient encounters and experienced attitudes and language that rub me the wrong way as well. I've seen providers treat patients completely differently based on race or ethnicity, sometimes while even discussing racism in between patients. If all patients were made to feel welcome and safe on a regular basis, then people would be more willing to collaborate and health outcomes would improve. And this, the last bullet point on this slide, comes from a study in a pediatric journal that examined nearly 173,000 operative procedures over a five-year period, meaning the finding is a valid one because the study was adequately powered to detect difference. So when the pandemic really started to be appreciated, it was described as the great equalizer. That is how people saw it. I mean, how could an infectious disease discriminate, right? Well, we're going to get into that question a little bit. So this slide presents the rates and death rates for COVID in New York City as of this month. On the left, we have cases per 100,000, and on the right, we have deaths per 100,000. In both slides, the darker the color, the higher the rate. So in the cases, the lowest case rate areas had less than 700 cases per 100,000 people, where in the darkest colored areas, there were almost 20,000 cases per 100,000 people. In fatality rates, the lowest fatality rates were less than 50 out of 100,000, while the highest were 1,137 people per 100,000 patients with COVID, or per 100,000 people who died. What does that really mean when you look at the numbers? Out of 100,000 people, this is very, very discontinuous based on race. Out of 100,000 people, 268 more Black people, and 3,131 Latinx people have been diagnosed with COVID. And death rates are even more stark. The death rate for Black people is 1.7 times as high for White, and for Latinx, it's 1.35 times. And that has not changed at all over the last year. Which is why we look at the population dot map from the 2010 Census, with one dot for every White person, one green dot for every Black, a red dot for every Asian person, and a orange dot for every Latinx. If we look at those distributions, we see those overlap. Black Americans are more likely to be infected and die from illness. The reasons for this include pre-existing issues such as structural racism, inequality and poverty, and a higher likelihood of living in, quote, hotspot areas, as well as significant over-representation in jobs that are considered essential. We have seen similar trends for our Latinx and Native brothers and sisters as well. Next slide. And what about kind of the disease on an ongoing basis? We talk about vaccination rates, and where are people most likely to be vaccinated? On the left, we have vaccination rates with the lightest color is less than 30% of people being vaccinated. The darkest color is 70% or more. On the right, we have COVID vaccination rates. So it may be that part of that disparity in vaccination has to do with the ability to get vaccinated. And this image kind of speaks for itself, but the more things change, the more they stay the same. So how do we wind up ignorant of all of this and its impact on how we operate? Let's talk about that. All righty. Do we have some Marvel fans out in the audience? We have to because statistically, this was officially the highest grossing movie of all time. This image is one of the preview ads. 13 characters are on prominent display, but only 12 names appear. The poster had to pass through many hands and many layers of approval, but it wasn't until the ad was out on social media and Black Twitter said, wait, wait, wait, wait just a second here. Why isn't Okoye Danai Gurira's name on the ad? Now, obviously, this was not intentional because Marvel wants everybody's money, but they still felt susceptible to it because it's a very real thing that we contend with. Next slide. So what's implicit bias? It's an unconscious, unintentional bias that's automatic, activated without our conscious control, and theoretically operates outside our awareness. What that means is that stereotype-confirming thoughts pass through our minds without raising any alerts, as you may have noticed with the Bandana Kids earlier in the talk. That means that these thoughts are affecting our decisions and our behavior, but not our knowledge. So we'd like you to look at these headlines and tell us what you notice here. There's patterns to these meanings, right? For the Black individuals, the headlines often highlight problems, whereas for the white individuals, they portray them as a brilliant science student or somebody who is bullied. The pictures that are chosen are different, right? And the things that they choose to point out are very different. But there's a pattern here that often kind of gets missed because the real pattern here is that the Black men are the unarmed victims of violence by police or police surrogates, and the white guys are all bombers or mass shooters. And, yeah, we have a disparity in headlines. Another way that this plays out is in this study, for the study, it was repeated with two groups. This set of results is from college students. Participants were given scenarios that described a crime and were matched with pictures of a kid who supposedly committed it. Some of them were misdemeanors and some were felonies. For each scenario, they were asked to gauge the age of the kid in the photo. On the left-hand graph, we have overestimation of age in years on the white axis. On the right-hand graph, we have culpability for the defense. The x-axis have three sets of columns grouped by race. The lighter bar in each group represents misdemeanor offenders and the darker bar represents felonies. So we can see that there's a substantial difference in how much college students overestimate the age of a kid suspected of a crime and their blameworthiness. What happens with police? Again, same study done with police officers. Lighter bar misdemeanor offenses, darker bars are felony offenses. On the left, we have overestimation of age in years and on the right, we have culpability. And you'll note that in fact, for a white kid suspected of a felony, police officer is actually underestimated their age, whereas for a black kid suspected of a felony, it's a four-and-a-half-year overestimation. The unwritten rules about skin tone are that generally, darker skin is bad. So for individuals in the public sphere, when described in articles that are critical or negative, they tend to appear as darker, as you can notice the difference between the two images presented here. As a result of being bombarded with this type of negative imagery, people unconsciously associate wrongdoing with darker skin tones. Darker skin youth and particularly boys and adults report more experiences of racial discrimination and microaggressions and are more likely to be considered guilty regardless of whether that's the case or not. Next slide. So, let's talk about the R-word. But I'm not racist. So, we have been talking about implicit bias, but here's the problem with that. We use it because it allows us to avoid thinking of ourselves, being more introspective and thinking of ourselves as racist. Because unconscious, and I would never think to say such a thing on purpose, therefore I can't be racist, allows us to think of ourselves as good people, stay comfortable, which means we can avoid doing the often really uncomfortable work of self-examination to challenge and ultimately change our biases. Next. People, especially white people, often think of racism as something that is conscious, intentional, and extremely overt. It's not racist unless you're calling somebody the N-word or putting on a KKK hood. We think of racism as the dictionary definition, hatred or intolerance of another race or other races. But there's another way to think about this. According to Dr. Ibram Kendi, racism is a marriage of racist policies and racist ideas that produces and normalizes racial inequalities. Next. So, how about structural racism? Structural racism is a system in which our policies, practices, cultural representations, and other norms work to perpetuate racial group inequity. It privileges whiteness and disadvantages color and adapts over time and becomes part of the institutions and systems in which we exist and practice. It's not something that a few people or institutions choose, but it is a systemic, embedded, and ingrained problem. On to the next. So, remember this from before. Here we have the distribution of New Yorkers by race, with one blue dot for each white person, one blue dot for each black person, one red dot for each Asian person, one orange dot for each Latinx person, and brown dots for others. This is the median household income in MIT in 2019 by zip code. The darker color is indicating a lower household income. In the darkest shaded areas, the median household income was under $47k a year. In one particular zip code, we'll take Brownsville, for example, because that's where the signal is, like where I work. In that zip code in 2019, the average household income for a family without kids was $49,580. For a family with kids, $28,585. The federal poverty limit for a family of two in 2019 was $60,910, and for a family of four was $25,750. Note that that's not cost of living adjusted, so the poverty line in New York City is the same as the poverty line in other parts of the country. Put it in real-life terms, in Brooklyn this spring, less than 18% of apartments under rent less than $2k a month, which means that over 80% of apartments cost over $24k a year just in rent alone, meaning the entirety of a family of four's rent. This map shows the distributed severe rent burden, which means 50% or more of household income dedicated to rent. In New York City, the lowest ranking is nearly 12% of families in any given area who have severe rent burden. In the darkest colored areas, nearly 40% of families are paying rent that is more than half their household income. Public transportation. This is a map of Subway Desert. The bright colored lines represent the subways, and the darker shaded areas around them are 10 minutes walking distance from the subway station. What that means is that there are significant areas of the city without adequate access to public transportation, dramatically increasing people's transit time. The farther out you are, the more unpredictable things are, which means that it takes you longer to get to work, you might be late, that could potentially cost someone their job, especially in a minimum-wage or entry-level kind of situation. And it maps also onto this, which is New York City residents earning below $35K a year with commutes over an hour. So that's going to work for extremely low wages, spending over two hours a day in transit, and spending about 5% at least of your annual income on transportation, because that's the cost of a monthly metro fare. All of which may have something to do with this. The darker the color, the higher the rate of unemployment. The latest data we've got is from 2019, so pre-COVID, but certain areas of lower Manhattan had a 3% unemployment rate, while six neighborhoods in the Bronx had an unemployment rate over 11%. And all of that may have to do with this. So these two maps show adult incarceration rates for jail on the left and green, and for prison on the right. For both maps, the darker the color, the higher the rate of incarceration. Because people need to pay their rent. They have to meet their other needs, and if it's not possible to do so, given what we just saw, with difficulty of traveling for work, the unemployment rate, the rent burden, you have to earn money and put money on the table somehow. So the number of kids we've seen who have been locked up, doing things they're not supposed to be doing, starting at a very young age, is remarkably high. On to the next slide. So how does racism affect our health? Well, if you experience enough microaggressions, discrimination, segregation, all of these things will affect us in different ways and have an accumulative effect, especially if there are less resources to counter those experiences. The end result is going to be bad, and research has established the connection between experience and racism in a wide variety of adverse health outcomes. Next slide. As it pertains to mental health, similarly, the racism experience will become internalized. If you have limited resources and no counter narrative, it will manifest itself in ways like increased internalized behaviors, low self-esteem, and hopelessness. And while it's less intuitive, we can also see externalizing behaviors. For example, I hate myself, therefore I have no problem harming this person who looks like me, or nothing good will happen for me, so F everybody. Next slide. One of the ways we can deal with this, the aforementioned issues, is all of us doing what we can to make our own contribution. It's not sufficient to just not be racist, but because of the pervasiveness of the issue, we can't all be anti-racist. According to Dr. Kendi, there's no such thing as not racist. If, quote, implicit bias, racism, shapes our behavior, our words and thoughts, interpretations of other actions, we are still being racist, whether or not that's what we consciously believe we're doing. And it's who we start forcing ourselves to feel this discomfort of examining our own racism so that we can identify it when it's in action, which, by the way, is far less uncomfortable than being on the receiving end of it. We can't do the work required to change ourselves and change the racism that's deeply entrenched in our field and the world. Next slide. So some of the upcoming slide titles are things that you may have heard from patients. I want you to think about your reaction when you hear them. Now we're going to put them in the context of history and statistics. Sometimes it feels like somebody's watching me. Right. It's not paranoia if they're really out to get you. Next slide. They don't treat us the same. It is a very, very long history of racism in medicine, and psychiatry is no exception. Back in the 1800s, Blacks were described by professionals as, quote, better suited for labor and, quote, psychologically adolescent. Before, during, and after emancipation, the scientific community associated an increase in the incidence of insanity in Black people with freedom. And we have the Sir Aubrey Lewis, who was the chair of the London Institute of Psychiatry in 1965, associated Blackness with criminality and madness. Next slide. Did you really just say that shit? I'd like to turn everyone's attention to Dr. Benjamin Rush, who is considered the father of American psychiatry as he was the first to systematically study mental illness and is credited with having written the first textbook, systematic textbook, on the subject in America. He was considered a progressive at his time, and he was known for many important things, like he actually signed the Declaration of Independence, and he was an abolitionist, which was a very unpopular opinion at the time. But he, unfortunately, was not totally safe from racist ideas and beliefs as he promoted the concept of negritude, which is to say that dark skin is akin to leprosy, and the cure is to turn white. Next slide. Y'all done make shit up. You may have heard in practice, certainly I have, people feel as though doctors kind of just make things up. There is a historical basis for that. For example, quote, Negro diseases found exclusively among Black people, drape-till mania, Negro consumption, and dysthesia aethiopica, and then treatments for these conditions involved whipping. Oh, how convenient, right? Next slide. Y'all don't care about my pain. This here is a very powerful image, Dr. James Marion Sims, who's considered the father of American gynecology and actually invented the speculum. He also is known for having developed the surgical cure for vesicovaginal fistula by performing experiments on enslaved Black women without consent or anesthesia. Consent was not possible due to their enslavement status, and while some anesthesia was actually available at the time, it was not used at all during the experiments. Next slide. You're experimenting on me. So I hope all of you are familiar with the Tuskegee experiment, which ran from 1932 to 1972 and involved 600 Black women safely from the Alabama. It was a study of the natural course of syphilis, and the participants in the study were prevented from receiving treatment despite the fact that penicillin was invented in 1945. Even those who had joined the military and would otherwise receive treatment were denied treatment, so that the natural course of the disease could be studied. There were also, in the early days of medical research, many studies that were conducted in prisons. Notably, the Holmesburg prison is a prison in Pennsylvania where dermatologic experiences were conducted on prisoners that have lifelong consequences. You may be familiar with Henrietta Lacks, who was a Black woman who presented to John Hopkins with vaginal bleeding, and initially was told she was fine, but then eventually was diagnosed with cervical cancer. The researchers took a biopsy of her tumor cells without her knowledge of consent and found that they were, quote, immortal, which meant they could continue dividing over and over and over again, kind of without end. They started sending them around the world, used them to develop the vaccine for polio, many medications, vitamins, looking at AIDS, cancer, the effects of radiation, a multitude of different things. Hundreds, over 10,000 patents were registered in these cells, but the family not only didn't receive any kind of compensation, but wasn't even notified until the early 1970s when they started getting calls for blood samples because researchers had accidentally contaminated their cell lines with Kiva cells and needed genetics to be able to tell them apart. More recently, the researchers published their entire genome of these cells without the family's knowledge or consent, but in their genetic information. So I'm just crazy, huh? Glennon Washington King Jr. in 1960 was the first African-American man to run for president of the United States as a candidate in the Independent Afro-American Party. A few years prior to that, in 1958, he was committed to an insane asylum for attempting to attend the then all-white University of Mississippi. Next slide. Y'all still don't care about me. We might like to think of this all as in the past, but our current approach to pain control is not much informed by this history. You see this with the treatment of pediatric long bone fractures and sickle cell crises. In general, Black children seen in emergency rooms receive less pain medication than their white peers for treatment for similar or the same conditions. There's also a recent study of medical students that showed 40% of them believed Black people actually have thicker skin compared to whites and are less sensitive to pain as a result. Next slide. Nobody trying to hire me? On the left, we have the response ratios for Black job applicants and on the right we have for white. This is the percentage of people that are called back. The darker bars indicate having a criminal record. The lighter colored bars indicate no criminal record. As you can see, the white men with a criminal record are more likely to be called back for an interview than a Black man without one with the same resume otherwise. The Ban the Box application, given the racism of the criminal justice system, was one way that was supposed to address this by not making people indicate criminal records on job applications, but what actually happened then is the disparity became worse because people were using race as a proxy for criminal history. Next slide. This shit is rigged. This slide shows the lifetime likelihood of imprisonment for U.S. residents born in 2001. So, kids who are now 20 years old. For all boys, one in nine of them will be incarcerated at some point in their lifetime. For white men, that is one in 17. For Black men, that is one in six. Latino, Latinx men, that is one in six. For Black men, that is one in three. One in three 20-year-old kids who will be incarcerated at some point in their life. Next. Ain't nothing changed in 200 years. Have any of you seen the movie, 12 Years a Slave? Well, back in 1815, the man who owned Rikers Island was kidnapping free black people and selling them into slavery. This is current demographics on Rikers Island as of the 3rd of August. For reference, in New York City, the percentage of white people in the population is about 43%. Black is about 24.4%. Some other race, i.e. Latinx, is 15.1%, and Asian is about 14%. However, on Rikers Island, 59% of the people who are currently incarcerated are black. 28% of them are Latinx. Only just over 10% are white. And very few are Asian. Also of note, a year ago when we gave this talk, so in July of 2020, the Rikers population was 3,932. It had increased by nearly 2,000 inmates in a year, which is 50% or so of the population. So the crime rates in New York City have been kind of astonishing over the past year or so, and they've been tributing this to decreased incarceration and bail reform, et cetera, but we're actually incarcerating half again as many people as we were a year ago. So how about clinical practice? Are there disparities in treatment between black and white? Black patients are more likely to enter treatment via the ER or hospitalization, both for kids and adults. They have more use of emergency medication, seclusion, and restraints during hospitalization, tend to have a shorter length of stay and greater symptom severity on discharge, and are more likely to have multiple admissions. There's a higher likelihood of involuntary treatment across the spectrum of care, so that involuntary medication, seclusion, restraints while inpatient, involuntary hospitalization in the first place, and being more likely to be referred to assisted outpatient treatment, which is court-mandated outpatient treatment, and more likely to have that order renewed. There are also differences in medication choices, prescription rates, and dosages. So black patients are prescribed antipsychotics more often and at higher doses than white patients, and the doses are escalated much more quickly, whereas in minority-heavy mental health clinics, the rates of SSRI prescriptions are extraordinarily low. Next slide. How about risk assessment? Psychiatrists clinically overpredict violence by black patients and underpredict violence by white ones. So actuarial risk assessments are touted as a way of decreasing bias, but the problem is that they're normed on white populations, so they are more likely to have false positives in minority populations, i.e. it's much more likely that the person will be categorized as being at high risk of violence or reoffending when they are a patient who is a patient of color as opposed to a white patient. In fact, in a meta-regression, ethnic composition of the sample would be only a significant predictor of accuracy for actuarial risk assessment tools. So the higher the percentage of white people in the sample, the more accurate the tool was. This is likely due to the interaction of included risk factors and structural risk. Next slide. So when it comes to psychotic disorders, there are disparities there as well. The lower the average age of the sample, the greater the disparity is seen in, quote, prevalence. In correctional settings, race is the strongest predictor of schizophrenia diagnosis regardless of symptoms. And during the evaluation process, clinicians tend to underemphasize mood symptoms in favor of overemphasizing psychotic symptoms when looking at ethnic minority patients compared to other groups. And Dr. Cox, could you share your definition of schizoaffective disorder? Patient is brown, irritable, probably not sleeping, and paranoid because they don't have stress. Mm-hmm, a lot to do with trauma. And this book right here, The Protest Psychosis, actually details the history of how this circumstances came to be. And this 1974 Haldol advertisement was featured in there. And essentially, during the 1950s and prior, schizophrenia was thought of primarily as a disorder of disorganization and withdrawal, mostly what we think of as negative symptoms and present mostly among middle-class white women, housewives who were, quote, dissatisfied with their lives or had difficulties maintaining households or wifely duties. Then along comes the civil rights era, the 60s and the 70s. This coincided with the second edition of DSM being published, which rebranded paranoid schizophrenia subtypes as a condition of, quote, hostility, quote, aggression, and projected anger. Suddenly there's a epidemic in the rates of the diagnosis among black men, upwards of seven times more than white peers in the NIMH data. When this was further dealt into, this came back to biases of individual doctors affected by societal discourse, media portrayals, et cetera, including ads like this one. And there in the face were no substantial differences in severity of symptoms compared to white patients. Next slide. So what about antisocial personality disorder? There've actually been questions about the diagnosis since the 1970s. And R.L. Jenkins, who was on the DSM committee, raised concerns with the chair of the committee saying that psychiatrists will not put down as normal anybody who has repeated problems with the court and that this makes the definition of it, of the disorder subject to the charge of racism. So you'd think that would have evolved over time. However, in the DSM-5, the only nod is that they say ASPD appears to be associated with low socioeconomic status in urban settings, but that it may be associated with low socioeconomic status applied to individuals in settings in which seemingly antisocial behavior may be part of a protective survival strategy. Like jail, where you might have to stick it up to get fed that day, for example. Or the streets where a kid might have to break in somewhere to find a place to sleep. So this considering of context rarely has happened, but the diagnosis has significant consequences. However, the symptom count and the diagnosis itself don't predict misconduct in jail or prison. So clinically, how about trauma? Not all that. In a nationally representative sample of black adults, the 12-month PTSD prevalence is 3.6%. Lifetime prevalence is about 8.1%, which is similar to overall national prevalence rates for PTSD. It's worth noting that rates are substantially higher in those who have a history of incarceration. In inner city primary care clinics, where over 90% of patients are black, and often in economically depressed areas, nearly 90% have at least one major trauma exposure, and 25 to 35% screen positive for PTSD. In a primary care clinic, they're not there for mental health treatment. In a mental health clinic, the PTSD prevalence rate is about 50%. However, about 10% of patients in either setting have ever been diagnosed with PTSD, let alone receiving. Huge area of things being missed, right? In veterans, black vets are less likely to receive a diagnosis of PTSD or be awarded disability on their disability evaluation, regardless of whether or not they've had a pre-existing diagnosis. Slide. Kids are affected too, unfortunately. We see later diagnoses of autism spectrum, there have been times when I myself diagnosed teenagers for the first time. Black youth are much less likely to be diagnosed with anxiety or mood disorders and more likely to receive conduct or psychosis. In the juvenile detention population, there's a wide disparity between black and white youth, with black youth receiving 40% more likelihood of the diagnosis of conduct disorder. And as we mentioned earlier, you will see experiences of racism correlate with externalizing behavior as reported by youth and their parents. Next slide. So part of medical training is learning to identify patterns and make associations between symptoms clusters, demographics or situations. But the problem is that we run the risk of confirmation bias, which is the tendency to interpret new evidence as confirming our existing beliefs or theories. As in our cartoon, where, you've already decided I'm guilty, turns into, who's that witch can read mind? And so we have to figure out how to make those connections. And so we have to figure out how to make those connections. And so we have to figure out how to make those connections. And so we have to figure out how to make those connections. Who's that witch can read mind? Next slide. So what do we need to do to help change that? Check our own baggage. In other words, try not to be an asshole. Have a brief case to share with you guys. 25 year old male, single, unemployed. Oh, I'm sorry. Single, employed, lives with his girlfriend in the Bronx, currently in Rikers Island, charged with grand larceny. No prior psychiatric treatment. Says he has gotten as angry that he's not allowed to teach supreme mathematics. Gives meaning of each letter of his name and the examiner's names. Accuses examiner of being part of the quote 10%, intense eye contact, leans forward, gestures, speaks loudly and rapidly. What do you think is going on with this gentleman? Next slide. A lot of people think he's manic and psychotic, right? My man is actually part of the 5% Nation, which was a movement split off from the Nation of Islam. And it's considered a way of life, not a religion. 10% of people know the truth and keep others blind. 5% know the truth and wanna enlighten the 85%. And part of that includes supreme mathematics and a supreme alphabet, which is why all of the letters in the names hold significance. And it's something that was frequently referenced in hip hop, especially in the early 90s. And it had been referred by the FBI as a quote, loosely knit group of Negro youth gangs. So short answer is, yeah, he's not actually psychotic or manic. And one needs to be aware of the possibilities. Yeah. So another thing that we need to be aware of is our own terminology. So the observation of a behavior versus the application of our terminology to describe that. What do we mean? If I say, this guy didn't wanna talk to me or disclose personal information versus he was guarded, what do you think? If I say he yelled at me versus he was agitated, he was in a bad mood versus he was irritable, what do we think? If we hear the words antisocial, manipulative, malingering, delusional, paranoid, irritable, hostile, agitated, aggressive in somebody's chart, what do we think about them? Right? What do we anticipate before we meet them? And how do we treat them differently? Because these clinical terms have an impact on what we expect of patients, what we assume their diagnosis to be and how we approach them and interact with them. And that changes how they're going to react to us, which means they may be even less comfortable and less willing to share information and more kind of on the defensive because we're coming at them in a particular way. So we need to be very mindful of the words that we use. So how do we do that? We check ourselves. We need to be aware that our framework is our own framework, not the default. And self-knowledge is a necessary starting point for that. Sometimes those differences could be obvious, but sometimes they're less obvious. For example, someone's baseline level of trust for mental health professionals or for the criminal legal system, or how they show stress and cope with anxiety. I've known kids who get extremely intent and kind of in your face when they're anxious because they want to make the thirst of their anxiety go away and keep themselves safe. But that looks different than the kid who's hiding in the corner or asking for help. Another thing that we need to keep in mind is that our patients are often some of the most resilient, resourceful people that we've ever met. So regardless of the differences, we need to approach that with respect, not pity for somebody's perceived disadvantages. Reset framework. What do we mean by that? All the different aspects of our background, our history, our experience that shape our language, our expectations, our thought patterns, how we're perceived, situations, mannerisms, et cetera. All of these things go into our framework and we need to be aware of our own in order to understand the difference between us and others. Because there are substantial differences potentially in different norms. Yes, for example, sometimes you wear a hood and a sweatshirt, which means different things in different neighborhoods, like where we live in the city. Some of the justice-involved youth have to wear their hoods up, for example, to keep from being easily identified. And that spreads to their peers who wear their hoods up and it makes them more noticeable to the police. So it's different in different areas, even within the same small radius. There are also differences in how we're interpreting these. For example, that picture, Dr. March and myself have this conversation, what do you imagine is happening there? Because we were actually getting excited about something. For me, my style of facial expressions, gestures, rate and volume of speech, I get passionate and excited about things. And that often gets perceived as angry because I'm outside the norm for a white woman of my age, socioeconomic status, occupation, et cetera. For me, that might make somebody less likely to want to work with me or make them perceive me as defying authority, but it's not a safety issue, right? Whereas if I am a person of color, especially a man, and I am interacting with the police and I have the same kind of mannerisms and sort of interpersonal style that I personally do, right? And so those people are operating within their norms and perceiving me as angry when I'm not, that's a problem. And it may very well be a safety issue and somebody's life could depend on that. So we need to be aware of those differences. You think about how you might interact with a patient who you see as angry versus one who's not, whether that might affect your style, your willingness to be around them, how cautious you are with your treatment decisions, right? This matters, right? It's people's lives that matter. On to the next. Colorblind is something we've all heard before, right? What does that even mean? It's really a way of putting yourself outside a situation that you're really not outside of. It seems to be used to avoid uncomfortable topics, but for those who are actually living it, we can't afford to be colorblind, no one can really. And we gotta do what we have to to live a healthy life for ourselves and our families. Next slide. So what's our takeaway? Being anti-racist. Until we start forcing ourselves to feel the discomfort of examining our own racism so that we can identify when it is an action, we can't do the work required to change ourselves and change the racism that is deeply entrenched. Moving on. And that is a very rapid overview of that. We'd like to thank all our kids for inspiring us, especially Keen's kids here who are adorable. And my cat who is also adorable and much less smart. Yes, indeed. Oh, good job. If you'd like to read more about the topic. Yeah. We have some recommendations. We can also add our book in as well because we've got a book coming out later this year, hopefully. Not Just Bad Kids. And yeah, ready to take questions. We also put our emails in there so that for whatever reason we don't get to it, follow me, feel free to reach out. Yeah, that is here on the last one of those slides as well. So any questions, go ahead and submit those in the chat. Laura. All right. We are at the end of our hour. So we will wrap it up here. Thank you all for coming this evening and joining us. And feel free to reach out if you've got any questions. Thanks all and have a good night. Thank you for joining us. ♪♪♪

racism

mental health

healthcare

disparities

diagnosis

treatment

systemic factors

bias

anti-racist

equitable care