I really want to thank you for joining us this morning for our panel, Identidad, Comunidad y Cuidado Mental Competente, Past, Present, and Future of Mental Health Care in the Latinx Community, presented by the APA Foundation and the Caucus on Hispanic Psychiatrists. Felix Torres, I am the current minority and underrepresented representative on the APA Board of Trustees, and I'm also the recent co-chair of the Structural Racism Accountability Committee of the Board, which was tasked with following up on the recommendations of the Presidential Task Force on Structural Racism Across Psychiatry. I'm glad to see a lot of non-Latinos, so for those of you who, I mean, Identidad, Comunidad, I think you all know what that means, identity, community, Cuidado, Cuidado has several meanings, it could be beware, it could be caution, but it's also care. It's also competent mental health care. So you may notice that we will use the terms Hispanic, Latino, Latinx interchangeably throughout our presentation. There's really no clear consensus of the correct terminology, and really the nomenclature is ever-evolving. Latinx culture is as varied as you probably saw in the abstract, as varied as the distances between the hot Sonoran desert to the warm Caribbean waters to the glaciers of Tierra del Fuego. We are, while Latinos share a common language, and I would say, having just returned from a trip to South America, we don't necessarily share a common language, right? We speak English, we speak Spanish, we speak Spanglish, we speak Quechua, we speak many different languages in Latin America. But while we share that common language of Spanish, that is really the extent to which we, the extent of what we share, because there are, of course, regional and there are national differences. There are also variations in history, ancestry, heritage, race, ethnicity, beliefs, values, religion, spirituality, family dynamics, and cultural identity. We are not a monolithic culture. In the United States, the Latinx population has grown by 70% from 2000 to 2019, and it's really been the second fastest-growing racial or ethnic group in the country. Unfortunately, while we represent close to 19% of the population, only 4.7% of psychiatrists in the United States are of Latinx descent, and even less than that are actually fully bilingual. Our panel today will focus on the past, present, and future of mental health care in the Latinx community, and our goal is for you all to get an understanding of the evolution of the care and the treatment of Latinx individuals with mental illness through the lens of social determinants of health in our population. So basically, what have we learned from the past, what's happening at the present, and what are the hopes for the future? We have an excellent panel of colleagues and friends here. As is said in the title, we're going to divide the discussion into past, present, and future. El pasado, although it doesn't mean that he's in the past, but you know, I saw you guys back there, it's like, huh, interesting choice of words. But he will be discussing how we have come to where we are at today, and that's the wonderful Edmundo Rivera, who's the Deputy Representative of the Caucus of Hispanic Psychiatrists. Speaking about the present, we have our mid-career psychiatrist and good friend, Hector Colon Rivera, President of the Caucus of Hispanic Psychiatrists, and the future, Sebastian Acevedo, who is a third-year medical student at Rutgers New Jersey Medical School. And I told you what I do in the APA, my 9-to-5, which is, you know, I never 9-to-5. I'm the Chief of Forensic Medicine for Texas Health and Human Services. There are no relevant conflicts of interest reported by the presenters. A couple of the learning objectives, which I already shared a little bit about, but appreciate the evolution of the mental health care and treatment of Latinx population, understanding the social determinants of health and how they affect Latinx population and our, I should say, our mental health, recognize the importance of culturally competent care in the delivery of mental health services for the Latinx community, and reflecting on those lessons learned from the past and the present while contemplating what the future holds for Latinx mental health. So with no further ado, I will pass it over to Edmundo Rivera, who will give us the perspectives from a senior Latinx psychiatrist. And he's in the present. Thank you, Felix. It's a pleasure for me to be here. Like Felix said, I'm the Deputy Rep for the Hispanic Caucus. So just to tell you a little bit about me, I'm in private practice in Orlando, Florida, basically. I'm an Assistant Professor of Psychiatry for Florida State College of Medicine. And despite years of private practice and doing and playing different roles and having different positions, such as Chairman of Orlando Health Psychiatry, I still maintain my feet in the community mental health centers. I'm working in a crisis unit in the Orlando area also. So I wanted to begin by just giving you a little bit of perspective on, you know, I don't want to say that the past 30 years of me, my work, and working with Latin communities also. So when I became a resident, it was 1988. And at that time, I was in Philadelphia. And we were closing at that time, what was called Byberry State Hospital or Philadelphia State Hospital, was one of the longest running state hospitals in the area. It is considered, for some people, at one time, it was like a house of horrors, basically. Byberry at some point had 7,000 patients in it. And so we were, as residents, we were asked the task of emptying out the hospital, which actually closed in 1990. Philadelphia is the home of Benjamin Rush, who is known as the father of psychiatry, of course. And he wrote the first book in psychiatric care. And it was his thinking that the disorders of the mind were illnesses and not just problems of the mind, basically. So just a little bit about a different perspective. With advances in basic translational clinical and population sciences, the field of psychiatry is undergoing positive transformational change. The practice of psychiatry is evolving to incorporate deeper understanding of mechanisms of disease, novel therapeutic approaches, reassured evidence-based clinical approaches, and adaptive systems and models of care. In regards to this, when I came into the picture, just to give you a little bit of history, DSM-III was revised in 1987. DSM-III was actually developed in 1974. Prior to DSM-III, most of the thinking, and in terms of the evolution of the DSM, DSM-II was basically more psychodynamic, included more psychodynamic factors and structures. And as we became or developed better research and improvement in treatments, DSM-III was created. It was actually in 1994 that the DSM-IV was developed. I'll talk about Oedipus in a minute. So DSM-IV was created in 1994, and then so on with the development of DSM-V, which I'll talk about in a minute. The reason I have the Oedipal face here, hopefully we all have basically gone through that face, because of the history of psychiatry and psychodynamic principles, which were evidenced in the previous iterations of DSM. I talk about Oedipus as a legacy from Freud, whether you ascribe to a psychodynamic point of view, or we have developed many other therapies since then. But one thing that stands from Freud is that the Oedipal face is an important face in development, and the Oedipal face basically is the time where child-referential egocentric and egocentric point of view changes as he develops distinctions between inner self and outer reality. Eventually this leads to the development and experience of emotions, and eventually to the development of personality, which is afterwards shaped by the environment. So this is the legacy of Freud that is still, we would say, viable today in our daily lives. Moving on to DSM-V, with the creation of DSM-V, the APA decided to get rid of the multiaxial system, but more so it also grouped disorders as they develop over the lifespan. So there's a method to the madness in DSM-V. The other thing about DSM-V is that DSM-V was created as a living document, so that with the development of technology and better access to research, it allows for changes as new findings emerge. So moving on from my Biberi days, I get to PROSAC. So PROSAC was basically the first SSRI, and it opened up a world of changes in psychiatry, in biological psychiatry primarily. So when PROSAC came into the market, it changed everything very quickly. Within a decade of its introduction, PROSAC had provided effective treatment for tens of millions of people who suffer from depression worldwide. It affected an equally momentous change in the increasingly open way the world views depression and mental illness in general. Both changes have been so extensive and rapid that it would be easy to overlook the history of depression. It is a condition that has haunted us as nearly as we can tell from our earliest emergence as humans. A condition, however, that has been elusive, invisible, associated with a dark side of our existence that could be poignantly evoked in words and images, but never until recently fully defined or completely acknowledged. So when I finished my residency training and went on to practice in Orlando, I joined a group which developed one of the first behavioral managed care companies in the U.S., for good or for worse. We had a contract with Disney, and so Disney employees could only see us as providers. We used to see from the people that cleaned the streets to the characters, everybody at Disney. We used to, at that time, say that we kept Disney running on PROSAC, basically. So PROSAC did constitute a major change in the way we treat depression, for example. A lot of the research into serotonin and the improvement and the development of new medications have come out of the initial stages of the development of the newer antidepressants. So we're now moving on to other systems and other neurotransmitters, et cetera, which maybe the president will talk about. Now in regards to treatment and working with Latino communities, I bring up the biopsychosocial model because it's a model that I was trained on, and it's, I think, the viable model that we evaluate patients with. However, on the social component of the biopsychosocial model, we can add a cultural competence component, and so that we are more able to look at the cultures that we treat and the people that we treat, even though, like Felix said, Hispanics are not monolithic. We are joined by a language. We also have bonds of community and family bonds that I think extend throughout the Hispanic and Latino communities beyond what perhaps other cultures have. So we tend to hold on to our cultural values very tightly, and so I think that unites us in a way. At the same time, Latinos may, like any other culture, may present with different symptoms and manifest symptoms of mental illness in different ways. In Puerto Rico, for example, we used to have this symptom called, or basically a finding of women that used to come to an ER, for example, and just screaming and hysterically sort of looking like convulsing. They used to call it ataque de nervios, and so then they would get a sedative in the ER, and a few hours later, they would wake up and be fine. Today, those symptoms have evolved, and we know that those are really severe panic attacks. The other way we can look at culture, for example, is that cultures are dynamic, and they are constantly evolving. And so even in the Latino communities, symptoms and the expression of symptoms usually tend to evolve and may become something else just the way that hysteria gave way to paranoia in developed countries, the same way as an ataque de nervios. And also, what I find in my years of practice and involvement with the Latino community is that I've worked with patients of Puerto Rican descent as well as mostly Mexican descent, at least in my own practice. In the past few years, in Orlando, there has been an explosion of Hispanics moving into the area. Orlando has become a mecca for the Latino community, and there's hardly a place in Orlando that you don't hear Spanish spoken. So we are, these days, inundated by Latinos from everywhere, from Colombia, from Venezuela, from Mexico, from Nicaragua. All the South American and Central American countries have a space in Orlando at this point, and we are tasked to basically work with them, work with those cultures, and identify how they express symptoms and what sort of makes them tick. The way some, I think, in a way, working with some of the communities, such as the Puerto Ricans, I worked, I must say, I worked at one time at the Asociación de Puerto Ricanos en Marcha, which is a community mental health center in Philadelphia, and this is what gave me exposure. Initially, I was a resident still when I worked in that center, and most of the people that came were from Puerto Rican descent, and most of them had a lot of trauma because sometimes they could be sitting in their living room and there were bullets coming in through their windows and so at the time just the like I said the SSRIs were just beginning to be developed so we had to use a lot of benzodiazepines because there were not too many other medications that we could use other than antipsychotics which were not the best at the time of relieving anxiety and depression so other than that as I as I moved on and continued to work with those communities I find that in and the time that I've been in Orlando some some populations interpret symptoms in different ways so what I see from my experience with the Puerto Rican community is that Puerto Ricans tend to to express symptoms and experience symptoms as disabled basically and so if you don't if you don't know that beforehand you sometimes cannot work with that patient to get them back to where they need to be to work to be in remission of their symptoms whereas the Mexicans I guess because of their status as immigrants they look at it in a different way they they they come to you because they have to because they're not feeling well but they want to get well and they want to get back to work and they want to get back into life basically so they that they come with that drive I think that Puerto Rican diaspora in the United States initially when we started coming we don't we were you US citizens and so we did not have that drive in a way that the immigrants have so we could always go back to Puerto Rico if things were not going well here so I think that established a precedent in terms of how patients now tend to interpret their symptoms and how what they what the symptoms mean to them basically the the other thing is that that as cultures change I think the younger generation is changing recently my my daughter who just became a therapist was telling me about a young patient that was being told by her grandparents that why was she seeing a therapist because she wasn't crazy and she found herself educating her grandparents about why she was seeing someone which is a lot of progress I think in terms of our evolution and and basically the way stigma has diminished and and the way we can get rid of stigma in general the patients that I see now are different from the ones that I saw when I started about almost 30 years ago Latinos are more accepting of mental illness they're more accepting of expressing symptoms and coming for help which is really of great interest and support so with that I just wanted to say that as we have developed more therapies we can help patients with with different different modalities of treatment medication is not the only one psychotherapies work and the the work of psychotherapies is amazing that's one thing that has stood the weather time is psychotherapy perhaps and medication both together work better than either one alone there's other modalities of therapy that we have developed even running for example can help with symptoms you know exercise there was a recent study where they compare Lexapro and running they had patients assigned to run so many days a week and and also another set of patients taking just a medication and the runners basically with the assigned running that the results were really close together in terms of resolution of treatments of symptoms of depression so there's more to explore there's also the microbiome and some people say you are what you eat so those are the new developments and new opportunities for us to help our patients in a better way moving on to a little bit of the social determinants of mental health the the APA just at the assembly today approved the not the creation but the committee was created already we just need to approve the work of the committee on social determinants of mental health so that was done today at the at the assembly and in in in talking since I'm not going to expand on social determinants of mental health clearly there's many such as health disparities health inequities risk factors protected protective factors social norms and public policies those in terms of our standing as Latinos and perhaps a minority in this country do impact us to a great degree but hopefully we're making inroads to to improve those in better ways and with better treatment and lastly I wanted to say that in terms of the social determinants of mental health you have to take care of yourself because you're tasked with helping patients over the next whatever years you practice psychiatry and if you're not healthy or if you don't look after your health you cannot help people get better in my opinion so we just have to look after ourselves prevent burnout it's important for us to do that because the work ahead is is quite difficult and our task is although improving our tasks it's not going to be easier especially these days that we have so much perhaps violence in in our country and in some ways the children that are growing up these days with drills in schools constantly they sort of have to walk into schools with fear and that can make an impact in their psychological lives eventually so their brains in development so exposed to basically traumatic events and also being having to have that fear system activated constantly when they go to school the younger generation of psychiatrists are the ones that are going to be tasked with dealing with that and that doesn't it's not going to manifest now but it's going to manifest as they grow so as we know not only social media is a contributor to increase suicide depression anxiety in the young population in this country and so we need to do a better work in that area so finally I just leave you with this picture this is sort of what I do when I when I try to clear my head and take care of my mental health and take care of my health overall thank you I don't know where we were you going in that picture that's not home right that's not your castle so I'm Hector dr. Colon River I'm the president for the Hispanic caucus I work for a for 8 p.m. which is a non-profit I think I'm on the mention it as a session for today can you imagine so I'm the medical director not when he was a resident being the medical director for about three four years now I also work for University of Pittsburgh I do telemedicine been doing that for since 2017 so I run an inpatient unit from Philadelphia my apartment in Pittsburgh so anyone who wants to talk about technology please ask me questions after the presentation um so before I start my speech I mean where are you guys coming from and what states it's just want to know who we have in-house what states Texas Iowa okay New Jersey Indiana okay Illinois New York okay I know Georgia I know there are some people from Spain too so Puerto Rico okay what equal so all those places have Hispanics right they have letting eggs and probably you guys see patients that are from Hispanic descendants it's oh so welcome welcome um so talking about the present is kind of hard because whatever we do today is already the past right or it's gonna become the past and whatever we plan for tomorrow is kind of the future so present is something that doesn't last long okay so talking about presence a little bit tricky because we still using things from the past I mean we have more than Prozac right now but still not enough so we're looking for the future already so with that being said I mean we know the present I mean right now I'm in Philadelphia so about probably our population Philadelphia is about 17 18 percent Hispanic which is a lot I mean I see about I mean I have in my clinic about 2,000 patients 90 percent of them are Hispanic okay which is which is a it's a lot right from that probably 90 percent probably 60 70 percent does not speak English or they understand but cannot have a conversation okay so data I mean say that probably in the next 30 years is gonna be more complicated right you're gonna have a lot more people that probably do not speak the language or do not only coming from different places so that's about one in four of the people living in the US that's crazy right one in four so there's like about 20 something people here right so one in four imagine that so that's a lot of people and I think FedEx mentioned that only three four percent of the workforce are ready or understand the culture or speak the language just just think about those numbers and I don't know who was on the opening session yesterday but Dr. Brendel, Dr. Levin, Dr. Levonis all mentioned what we're dealing with right now right we just went through a epidemic right a COVID epidemic but now we're dealing with a mental health substance use disorder epidemic right and it gets more complicated when we're talking about Hispanic mental health because we don't have the force we don't have the workforce and the cultural competence or humble or I mean some people use different expression to describe what we need that cultural understanding it's not enough to only speak the language but we need to understand the cultural you know I want to just mention that the APA is doing a good job I think they're doing a better job now we have the first website in Spanish LaSaludMental.org okay it's a new project from the APA and it's not only information in Spanish but it's information that is cultural humble to our patients members and the community so mental health care in Hispanics I mean we see that I mean this is recent from 2016-2020 still the measures are not I mean the disparities are still there we see that not only on mental health but also physical health cardio other other physical complaints but in in mental health we see that treatment for counseling the last 12 months it's getting worse adults with major depressive disorder in the 12 more receiving treatment it's getting worse children's ages 12 to 17 with major depressive disorder in the last 12 months received treatment it's getting worse so you see the pattern right is it's getting worse I mean you Google Hispanic Hispanic treatment and you see how different states have decreased the services the access you know the the options for our community Hispanic multiple multiple states have decreased the access to our patients and I mean that's that's out there it's really difficult it's not impossible that's why we're here to talk about it I mean there are different barriers that letting ex-Hispanic people are more likely to seek help for mental health disorders from a primary care provider so they don't we don't see them I mean and that's that's because of multiple multiple reasons I mean could be transportation it could be because they they work multiple multiple jobs it could be because the mental health providers do not speak the language it could be because we there's they're not enough mental health providers in their area okay also there is the stigma of seeing someone that is a psychiatrist a therapist such a worker because that means that you know the local as a moon to say you know that that patient that his daughter saw like grandma grandpa doesn't understand they don't understand what mental health is so a lot of barriers poor communication with health care providers often an issue mental health problems can be hard to identify because letting ex-Hispanic people are often focused on physical symptoms and those psych symptoms during doctor visits I think Mundo mentioned that back in the interview but that it can be seen as a physical a physical situation physical reaction but we forget that you know it come from the mind come from the psychic of that person 80% of letting ex-Hispanic people in the US do not have health insurance which is a big big deal I mean in my clinic I see people without insurance but probably 96% of my patients are Medicaid so Hispanic that have multiple jobs that work they have transportation issues I mean we often don't don't see them you know I see most of my clients do not work they have low education level but they have sometimes the time to come to see me I work extra hours to you know to let me because there are people that do not have that option right they need they need the extra hours and they need us to work weekend sometimes to be able to to get treatment so that's that's a barrier there as well 2018 about 60% of letting Hispanic young adults 18 to 25 and almost 40% of adult 26 to 49 with a serious mental health did not receive treatment I mean that's not striking at all I mean that's pretty that's that's what happened in our population and nearly 90% of letting ex-Hispanic people aboard over the age of 12 with a substance use disorder did not receive treatment so I'm addiction to psychiatry by training and it's really hard I mean it's more stigma I mean dr. Petros I've only mentioned that for the next year the APA want to focus just in addiction right because it's it's a big deal I don't know if you guys went for a walk in San Francisco in the last two three days it's tricky it's really my my hotel is like two miles from here so I'm going long walks and it's pretty striking what you see I'm from Philadelphia and I'm amazed what I'm seeing in San Francisco and Philly is like always in the top three of overdoses especially my offices are around Kensington I don't know if you guys familiar with Philly but that's the mecca of opioid fentanyl psilocybin shrinks you name it okay here's more meth and you see them with the pipes and all that so if you have not seen it please take take a walk and see that you are guys are psychiatrists you can you can tolerate the scene I think it's a it's a good experience and you just you know kind of grant you to what we're seeing outside our offices I think that's I think it's you should take a walk let's put it that way going back to a health insurance I mean you see on the on the screen and probably have no change to 2018 so why versus black or so Hispanic we see you know around 40 percent before 20 so it has improved a little bit to do the different rules bills on the on the state Senate but still we're still struggling and this doesn't include immigrants remember you know a lot of people come from different count countries and they don't have insurance they don't have papers and don't have IDs right we have we just got a grant at 8 p.m. so simple to the can you imagine that's 8 p.m. and we see undocumented clients as well patients and I think that's that's a pretty big deal we just don't ask for anything just just a name and we we see them okay we also pay for their treatment and medications so when meeting with a health professional ask them if this is for patient always when they meeting a new PCP cardio surgeon whatever I mean please ask them if they have any experience treating Hispanics. I think that's really important. Not only do they have translators, I mean, they always focus on having translators on those clinics, but it's more than that, okay? Recently, I moved my mother from Puerto Rico and, I mean, let me tell you, that has been a mission. Not only because she's a Medicare patient, I don't know who has called Medicare for, I mean, who has called Medicare for a patient or, oh, my God. It is a mission, and then you get a translator that you don't understand the Spanish, they're talking sometimes. So imagine my mom, 75 years old, just, you know, first time in Philadelphia looking for insurance, right? And both me and my wife are doctors, and we couldn't understand what was going on. So imagine a patient, you know, your patient, 65 plus, no support, no grandkids, kids are not available because they're too busy working. Imagine that person looking for help. So I just lived that with my mom, and, you know, she's pretty supportive. We had the resources, and it was hard, okay? So, you know, give me a different perspective about what we do. So always ask, you know, if you are Hispanic, I mean, you guys are patients too, for sure. I mean, I'm a patient. You see, I have doctors, and it's really important to ask them. I mean, have you treated other Hispanic Latinx people? Have you received training in cultural competency? Which these days, I mean, all, like, big health system, they have training that is mandatory, I mean, because it's kind of a sexy, hot topic these days, you know? But it's mandatory. So is it great? I don't know, because, you know, getting the training and the practice is two different things. You know, implementing and seeing it in action is a different thing than just watching the webinars, for sure, but how do you see our, you know, how do you see our cultural backgrounds influencing communication in my treatment? So that's another question, a good question for your primary care or any doctor you're seeing, any provider. Personalized precision medicine and Hispanic Latin health. Well, there's a lot of advances. There's a lot of research in Hispanic Latinx population, but we still have low representation, okay? And that's a big deal. I think this, you know, this year, the APA is focusing on innovation and, you know, and the future and the motivation of psychiatry. So innovation, I'm pretty sure if you look at the news these days, there's a lot of AI talking, right? I mean, what's the social media, AI. So that's the future, but it's kind of the present. Right now we're talking about it. But it's tricky, right? Because, I mean, AI and social media feed from the stereotyping and the bias and social things that we are living right now. So I don't know how many coders are out there that are Hispanics, or I'm not sure. But AI, what's the name of that chat? Chat CVT. Chat CVT. And all these news apps are made not with a lot of input from Hispanics. So, you know, just watch out, right? We're still, it's the future, but we're still living with those stereotyping, stigma around our communities. So we need more people, you guys, everyone here, to advocate for more, right? For more representation on that. So I use these on my practice. I mean, this one and the next one, just to think about how to map the role of cultural in our practices. And this is from the tip of 59. So SAMHSA created this. So it's a lot, right? I mean, we know that people that keep traditions, cultural, in their family, in our patients, just continue to follow traditions and cultural are more protected. They have more protections. I mean, that's pretty clear on substance use disorder. For example, someone that just moved from Puerto Rico and continue tradition from home has better protection and probably respond better to treatment than someone that is isolated and do not practice any traditional culture from where they're coming from. So they have a higher risk of substance use disorder or having risk of other comorbidities. So keeping cultural, I mean, please teach your kids Spanish. Please take them to Puerto Rico. Take them to the country you're coming from and don't forget where you're coming from. So it's a protective factors. So other things that are important when we talk about our patients, so legal, socioeconomic status, for sure, time in the community is really important. Health and belief, oppression, discrimination, values and the family values in the community. And of course, religions and family. This is for workers, so cultural skills, cultural knowledge, cultural awareness. I mean, if you are measuring the people you work with, I mean, I'm a medical director, so I need to meet and supervise, I have like 34 therapists that I supervise. So that's a lot of people. Most of them are bilingual, but they're coming from different places. So I need to understand what their cultural backgrounds are and the traditions and what they believe in, especially because not all Hispanics are equal and they're seeing people from different places. So it's really important to meet with them and talk about their beliefs. The workforce shortage is a big deal. There's a high turnover. I mean, cultural, the diversity, equity and inclusion, training and development. I don't know how many of you guys are in administrative positions, but it's been really hard to find bilingual providers in Philly, probably the same in your states. But it's not only finding them, it's keeping them, right? We have seen trends, the baby boomers, and now the millennials and the Gen Z. I mean, who's familiar with the Gen Zs? They're my favorite because, do we have Gen Zs here? There you go. Yeah, so priorities have changed. I mean, baby boomers used to look for a job that they want to stay, they want a career. They want to stay in that company for 45, 50 years. They want to retire in that company. Millennials are kind of middle. They want some experience, but they move around. Gen Zs is a different story. They want to create, they want to be independent. They don't stay for that long. They create their own positions. So it's a tricky trend, what we're seeing, but we need to model to that, and we're seeing that also in the Hispanic community. And of course, it's harder to get, find, recruit, and retain a staff. So the market's super hot. Whoever's looking for jobs right now knows that. We're seeing the trends. This is pretty interesting. I mean, in the past, so now the trends is looking for the salaries, but there is something, the work-life balance. It's kind of a hot topic, right? We're looking for that. I think COVID also put that on the plane, that people want more, be more flexible, right? And I think managers are not used to that, and we're having a hard time putting that on balance, right? I mean, you need to work, but also I understand you want your time off. So this is pretty interesting. And of course, onboarding average time to hire is 3.5 weeks. So sometimes you hire someone and then you train them, and then they leave in a month. So that's really, I would say annoying, but it happens. This is the present, people. This is the present. So see post onboarding one year long term. So yeah, it's investment. It's a commitment to keep people with you, work for best practices. I'm a fan of telehealth innovation and technology. I know the, I mean, it's not the solution, but it helps. We're hybrid, and our practice, we're hybrid. I don't know, I mean, who does not use telemedicine these days? I don't think you will survive. I mean, it's like, it's really tricky. You need to do some or, because I mean, bringing patients back to our offices have been, it's been tough. It's been tough, especially for Hispanic communities. I think they like it. They like to stay home. They like to, I mean, to have the option. Clinical trials, I mentioned this because it's still the mistrust and distrust on the system, bringing people. So whoever have this farm going to your offices, please ask them how many Hispanic you have on your studies. I mean, they will say, I need to ask that question. I need to call my manager because I don't know. I don't know. I don't have the answer, but it's not a lot. So we're still dealing with poor enrollment, a lot of attrition rates in these practices. I mean, and we need, it's tough to use a product that we don't know that's gonna work in our population. So here, you know, in the snapshot, you see how Hispanic or Latinos are the orange, so pretty much, I mean, like 10, 13%, not a lot, right? So it makes it harder to select a product that you don't know that's gonna work on your patients. I mean, just asking for more, you know, more. We need more data. So we need more diverse participation, so we need to engage patients in trials. Logistic, recruitment, retention practice, workforce diversity is key to do this. We need to be sensitive, competent, and be aware. Eliminating the language barrier. Yeah, I mean, that's great, but I think it's not enough, it's not enough. And just be careful, you know, announcing yourself as you speak Spanish when you're done. I mean, sometimes I struggle with that. I find sending my patient, I'm an addiction psychiatrist, so finding a rehab or addiction, a detox, whatever, I mean, a sober house, or they announce themselves as they are bilingual, and then when you get there, my patient, they don't have anyone that speaks Spanish, not even Google Translate. They don't have Wi-Fi from that place. So my patient relapsed the next day, you know, and you're not doing a good job, you know, you're announcing yourself as someone that speaks Spanish. Please don't do that. If you work for a place that do that, I mean, talk to your manager. I mean, there are technologies there. I mean, you know, you can use telehealth to bring, you know, consultants or people that cover for those patients, please, please, please. I mean, it's a big deal. People are dying from overdoses, and that doesn't help the situation. So I think that's my presentation. This is the present, which is the past already. So we keep working on that. Thank you, guys. Hi, everyone. How's it going? My name is Sebastian Acevedo. I'm the incoming president-elect of PsychSign, which is APA's official student group. So if we have any trainees in the audience or anyone that works extensively with trainees, have some flowers, come talk to me afterwards. I'm also a medical student. So when Dr. Colon-Rivera asked me if I wanted to be on this panel, I was torn between either seeing another baby being born at 4.30 in the morning or coming here to talk about a topic that I'm intensely passionate about. So you can all imagine how enthusiastic I was about the whole thing, and it's a pleasure to be here. Now, I will disclose that before I start talking about the future of Hispanic mental health, I should really state that I was trained qualitatively under a wonderful PhD researcher, and a big part of qualitative research is before I start talking about anything, I should disclose my positionality, my background, and who I am, because that will influence the recommendations and perspectives of the subject at hand, in this case, the future of Hispanics, which is a very broad topic. So first-generation Colombian immigrant. I was raised in a household with a... Yes, yes, I'm from Beijing. So I was raised in a household with two blue-collar workers, and I say this because my perspectives are not encompassing that of Latino individuals who have had experiences such as undocumentation status, who have crossed the border, and who have been at the hands of a lot of adversity, racism, and political inequities, right? And I wanna be cognizant of that before I start to prescribe solutions for an entire demographic. So I wanted to start off by just talking briefly about where we are, right? And we know that Latinos, as was mentioned earlier, are one of the largest ethnic minority groups in the United States. Currently, they do make up about 19% of the U.S. population, and these numbers are expected to only grow. In fact, by 2060, they're expected to grow up to 28% of the U.S. population, almost a third of the overall. I will caution this with caveats, which is if you all look at these numbers, although we are increasing in representation, those numbers are slowly dwindling. A lot of people speculate this is due to a lot of the policies that we are enacting, which discourage a lot of immigration. And this is problematic, but this is just to tell you all, Latinos are growing, they're here to stay, and whether we like it or not, we will need to work with Latino mental health in the future. Now, I do wanna get to the crux of sort of my argument here, which is how do we navigate the future of Latino mental health? And we've mentioned it earlier, but Latinos are a very heterogeneous group. When you talk about Latinos, and in fact, between one Latino to another, I open my mouth and I start talking in Spanish, and people have me pinpointed to like the neighborhood that I live in Columbia, it's that exact. Like Latinos know where you're from, and you know who you're talking to and the culture that you're communicating with. And so there's a lot of trends, and there's a lot of changes, and this will inevitably modify how we work with Latino communities. Historically, Mexican immigrants have been the largest Latino demographic. However, we have seen from the year 2000 to 2020, that the largest group that has actually been growing have been Venezuelans. When we think about why those patterns might be, we have to think about the political turmoil, the economic struggles, and or US policy, right? Historically, until actually the expiration of Title 42, many Venezuelan immigrants were allowed in the country as opposed to some other groups, because we don't have a good relationship, at least politically with that country. So I say this because we're not a monolith, right? And in the future, the groups that we have historically seen as representing Latinos will come and go, right? Because Latino migration patterns are influenced by very complex geopolitical issues, right? And this is really sort of backed up by the literature, right, which is Latino mental health doesn't happen in a vacuum. In fact, I found this wonderful article by Cervantes et al that actually cited that Latino mental health is actually a consequence, very complex pre and post migration patterns, right? The way that we see a Latino identifying patient in the clinic for a mental health complaint is really structured by not only the home in which they came from in their country of origin, but also the neighborhood in which they eventually set up and started living here in the United States. And this has actually borne out in very complex ways. And the literature is quite contradicting when it comes to this topic. For example, we found that, again, in the Cervantes et al study, that Mexican immigrants were actually found to be more likely to be exposed to high levels of acculturation stress, which adversely impacted mental health outcomes when they presented to the clinic. However, in another study, Mexican ancestry was actually found to be protective for positive mental health outcomes. And this is just to show you all the state of the literature, right? Currently, a lot of the studies that represent Latinos are limited by small sample sizes. They are limited by the fact that there are really no systematic reviews or meta-analysis to speak of. And so the state of how nationality, background, and cultural ancestry impacts Latinos is really a gray area. But there is enough literature that I can point you all towards that does say that your nationality, meaning where you come from and how you identify as Latinos, does impact how you present clinically. And so this is a change of pace because I think nationally, the way we aggregate data and the way we represent Latinos is we just check a box that says, often, ethnicity, Latino, yes, no, and then we move on with it. But this is problematic because of some of this research that's actually emerging, right? And again, I just wanted to drive this point a little further by telling you all that we have found, overwhelmingly, that Latinos not only have different mental health impacts depending on where they come from, but COVID-19 has really complicated our image of Latinos, their health status, and what we can reasonably expect about Latino life expectancy. I'm sure you all have heard of the infamous Latino paradox, which was top of the mind for many researchers before COVID-19 happened. The Latino paradox is really born out of the fact that Latinos have unusually positive health outcomes and life expectancy, despite lower educational attainment, despite low socioeconomic status, and researchers were really confounded because Latinos had everything, at least the public health realm that we attribute with poor outcomes, and yet they were doing very well. COVID-19 upended that. But researchers, prior to COVID-19, they were thinking of salmon bias, immigration bias, or the fact that we were simply just undercounting Latino deaths. But COVID-19 really showed us just how flawed a lot of our data was, because the CDC, and I think I have it on this slide, reported that Latinos were about twice as likely compared to a white-identified individual that actually died from COVID-19. So this is really to tell you all that there is urgency to this topic. The way we previously understood Latinos has been shown to be problematic because of what we saw as a consequence of COVID-19. And this is where we introduced the mental health realm. So I had this question, which was, when you look into Latino literature and you look into the Latino paradox, oftentimes people say, well, one of the protective factors is social connectedness, right? Familialism, right? Just values of social connectedness and support. But when you think about COVID-19, it was the exact opposite. It was a lot of social isolation, loneliness. So I had a research question during my MPH year. We carried out a cross-sectional survey. And so I wanted to see whether or not Latinos, after controlling for a lot of these upstream social determinants that we come to associate with poor health outcomes, if they were significantly more likely to have poor mental health after controlling for those factors when increasing when having more loneliness or less social connectedness. And what this research study actually found is that it was true. For Latinos, social isolation actually correlated very strongly with poor mental health outcomes. And what was really fascinating is that when I talked about this, when I talked about COVID-19 adversity, I focused mostly on mental health correlates, meaning did the person experience greater anxiety, depression, substance use, et cetera. And in the context of this analysis, I actually do want to point out that things that we normally associate with poor Latino outcomes during COVID-19, such as sex, essential worker status, and reporting transportation barriers, were not associated with heightened COVID-19 outcomes. And again, this is because this cross-sectional analysis was done with mental health specifically in mind. So we have to think about mental health and physical health outcomes during COVID-19 for Latinos are very nuanced. And we can't prescribe a one-size-fits-all issue or social slash public health paradigm that we need to address to really target their needs because it's very nuanced. Unfortunately, though, as Dr. Colon-Rivera and I think all of our panelists have said today, there is a lack of providers who both speak the language and who are able to provide culturally competent care. And this creates a vacuum, right? You don't just have 19% of your population who says, OK, there's no providers. I'm not going to seek health care. It's all good. I'm going to have undiagnosed depression. That doesn't happen. And unfortunately, during COVID-19, this created a vacuum. We weren't publishing articles in Spanish. We don't have information resources for a lot of our Hispanic communities. And so this became top of mind. And what we found is that Latinos not only experience greater social isolation, but they were trying to fill this vacuum of information of providers and of mental health services with whatever they possibly could. And this isn't an issue back in, I think, 2000. You would never think to see a front page like New York Times article on mental health and social media. But today, it's happening. And what we were seeing during COVID-19, and I'm sure if you all identify as Latinos, you will find your family WhatsApp chats were flooded with misinformation and a lot of the misleading content, because mine certainly were. And so fortunately, I don't want to be the bringer of doom when it comes to social media, especially as a future panelist here. I do want to caution that it is important for us as mental health professionals or aspiring mental health professionals to be a part of this conversation. And specifically, APA and Dr. Colon Rivera has really led the charge on an initiative that he mentioned called La Salud Mental. This is evidence-based, culturally competent resources for Latinos to actually visit on the internet. We have quizzes. We have case studies. It is all written at a level in which our patients can really engage with a lot of this content, and we need to do a better job of directing them there. And just to really underscore the need and the desire for this information, if you go on TikTok, I pulled this a couple of days ago, the search term mental health Latino had 83.4 billion views, meaning billion, which is incredible. And it's, of course, globally. But it tells you that if we choose to not participate in this rapidly changing social media ecosystem, Latinos aren't just going to not consume content. And especially with COVID-19, virtual communities are here to stay, and we have to be at the table when it comes to these issues. I also want to talk about more research-based representation when it comes to Latinos. I understand that publication, journal sizes, and the costs that incur when you choose to publish more lengthy data is a very hot topic issue, especially for any editors that may or may not be in the room. However, when we historically marginalize and or group Latinos under just one category, and we do not disclose where those Latinos come from, how they identify, we are doing a disservice. And this comes by way of clinical trials. This comes by way of large cohort studies. This comes by way of just our research needs to represent the people who we are talking about. And I don't expect this to look like a clinical trial can't feasibly do a subgroup analysis if they had an N of 20 on four different people who come from different Latino backgrounds. Like, I'm not saying that. I am saying, though, that we should publish where the Latino respondents are coming from and things like supplements. So researchers who want to understand who you're surveying, where are we lacking the data, and what groups of Latinos do we need to do a better job of outreach in, that they can look at this information. It all starts there. Because currently, if you look into Latino data on nationality and mental health outcomes, it's pretty marginal studies that have made it a goal to look at nationality differences. But why isn't all Latino differences considering this rich diversity of cultures and backgrounds? So I just want to pivot to that. And last but not least, we do need to talk about social determinants and how it looks like for Latino communities. We know that the Centers of Disease Control and Prevention has this model well-established. However, I do want to add an asterisk to that to say that social determinants for all have not looked like social determinants for Latino. And based on the data, based on the research, we are looking at a Latino community that is driven by their national origin, their generational status, whether or not they are documented or undocumented, their level of acculturation, and their primary language. All of these are factors that we have found, at least in the literature, to drive poor or improved Latino mental health outcomes. It's a very nuanced conversation. And that is my presentation. And I believe we'll move on to the panel discussion. Thank you. Thank you. We have about 20 minutes left in our presentation. Are there any questions from the audience? I see a brave person coming up to the mic. Hey there. My name's Jake Cross. I'm a psychiatry resident in Chicago. I treat mostly Spanish-speaking patients in an outpatient context. I'm in my third year. This was amazing. Thank you for this talk. Earlier in the talk, you mentioned that the quality of the interpreters can be challenging. And I was wondering if you could speak to that a little bit more and if your group has thought about how to communicate or interact with interpreters in a way that might facilitate improving the quality of the interactions. I've been thinking a lot recently about debriefing with interpreters in the mental health context and be very curious about your thoughts on that topic. That's a great question. And I don't know what system you work at. I mean, is it like a big system, small system? I work for small and big. I mean, I'm the medical director for a nonprofit, so pretty small. We depend on translators from usually insurance, like our big insurance is CVH. Community Behavioral Health. And it's tough. Most translators are not trained in psychiatry in the big systems, right? So it's a big deal, especially if you're doing, I hope you're not trying to do therapy or psychotherapy or psychodynamic therapy with a translator, because that would be really kind of impossible, right? But most of them are trained to yes or no, I mean, kind of small talk conversations. And when we get into psych, it's a little bit more than that. It's a lot of emotions. Emotions are really hard to translate. I move my hands a lot, I move around, kind of I will be the Hispanic that is diagnosed with hypomania and I'm bipolar disorder right away, because that's my personality. And that usually is not perceived by a translation. So, and it's hard. It's a great question, I don't know. I mean, I think the EPA could work in a, maybe a position statement or something to work on that kind of same way we're training our first responders and police, how to act or react to when we have civilians acting in certain ways, right? And how to dispatch mental health providers before dispatching the police. I think it's kind of the same concept. I mean, how we train that translator to be better mental health providers, because they're a part of the team at that point to take care of our clients. I mean, it's a great question. I need to think more about the be resolved. I mean, how can we track that? But I mentioned my personal experience with that, and my mom was super frustrated, right? With the situation. And yeah, she talked to me after that. I was not present, but she was super like, yeah, like, you know, in shock with how probably she would understand more if they speak to her in English than having that translator translating in Spanish. So, yeah. So we all have one language, but it is really a different language between different cultures. So some translators can express themselves in a certain way. You know, we all speak Spanish, but at the same time, the expressions can be different. And if you're dealing with a certain nationality and the translators and other nationality, some of the things may not come out some of the things may not come out in the language the same way as you would express them. And so, you know, some something gets lost in the mix, basically, so. Hi, everyone. My name is Arlie. I am just graduated medical school, starting residency in psychiatry, and I. What? The future, the future is in the house, yes. But just for context, like, I've done research on disparities in medications for opioid use disorder in Newark, New Jersey, where Sebastian trains. And, you know, our population is very robustly Latino, roughly 40%, but the reality is in our clinic that, you know, prides itself on being low barrier, we're not seeing numbers of Hispanic Latinos seeking care for opioid use disorder, for addictions. And I'm sure this extends out to mental health in general. So I'm wondering, you know, as somebody who hopes to continue to research disparities in mental health during residency, you know, I really hope to, you know, tailor my focus to the Latino community being a first generation Colombian as well. How do, where do we engage with the Latino community? And how, what, sorry. Where and how do we engage with the Latino community to encourage their engagement in mental health? I know that's a loaded question, but opinions. Hey, Arlene, how are you? So, so number one, I mentioned briefly the cross-sectional survey that I was lucky enough to be a part of, and we did some very uncanny data collection methods. For example, I live in New Jersey. There's like a bus that leaves Northern New Jersey and goes to Atlantic City, which is in Southern New Jersey. And we heard that those buses are always Latino focused and so we literally went on this bus on a Saturday morning and we talked to a bunch of the people there. We consented them, we got the surveys out, and we got 50 surveys out of that one little like bus trip. These are individuals who I suspect that like a community health festival, they would not be going. And this is to say that unfortunately for people who are interested in doing research within psychiatry and who want to target Latino individuals with substance use disorder, for example, the interventions are going to need to look different. Some may say that that will challenge the rigor of the interventions. I am of the mindset that as long as we are pushing the envelope, we will reach greater inclusion. To tell you that I am familiar with researchers who have actually used, for example, clergy members as sources of referrals. So they've gone to Catholic churches and they've trained some of the clergy to actually identify a substance use disorder. And of course to do their counseling, to maintain confidentiality, but to also say, and I happen to know that there's this great Latino addiction psychiatrist in the area if you want to talk to them, right, no pressure. And so those studies, and I have to actually send you the references for this, they have increased diversity and they have increased recruitment and they have added nuance to a service that Latinos already seek, which is we know addiction is very morally and religiously complex, especially when you have a very spiritual group such as Latinos. So why don't we capitalize on those tendencies and bring the healthcare to them? So it's a big question, but I'm hopeful that you'll be a part of answering what that looks like. And one thing that I guess, the silver lining of COVID is the fact that we're having these conversations, right? We're having more conversations about mental health. You mentioned in your presentation about 80 plus billion or 100 million as some Latin American countries say, there's no billion in Spanish, views or search terms for Latino mental health. So we need to make sure that we are on top of being the voices and the right amount of information and not misinformation. There's a lot of misinformation out there. So there's plenty of spaces for us to work within. You were in my mental health show. I was one random day, I got a call from El Mundo Boston and they're like, we saw you, I don't know where, we want you to be on our mental health show in the middle of COVID because of the fact that the conversations were happening and that we're now going on the third season and we've learned a lot in that journey. We were having like a half hour show that people were dropping off in the first two minutes. And now we just, in the third season, repackaged it to short 15 minute, but with digestible bullets and digestible flashes that we can use throughout the week so that we can have that information out there. We really need to exploit that as social media is where people are fortunately or unfortunately getting their news nowadays. Also, I mean, we are an organized medicine organization right now, right? I mean, APA is organized medicine, but we have a lot of organizations that are triple APASM that, I mean, we need more leaders that are a representation of our communities. I mean, we don't see that on those smaller organizations. I mean, triple APASM don't have a lot of Hispanic addiction psychiatrists. And that's really important when we're talking about research. I mean, they represent what we do. I mean, they are the ones that go and lobby in DC for more resources for research. So it's not only what we do on the ground, but we also need to keep in mind that we need more people like you, Sebastian, to run for those positions, right? So we have voice, we have representation in these organizations too. So that's really important. And with that, I want to mention that Hispanic Caucus is meeting today at 5.30. So please, I want to see you guys there. I mean, we're talking about the present, the future, and the past of the Hispanic Caucus. Room 21. Hi, my name is Elizabeth Alegria. I have a quick question. When I completed my graduate program at Columbia University and also my training at Bellevue Hospital in Manhattan, both of these institutions did a wonderful job of encouraging me and the other people in my cohort to do what we could to make services as available, as multiculturally competent in the regions where we would be providing services post-graduate work. And subsequent to that, I've moved to Austin. I've opened up a behavioral healthcare organization that serves a lot of regions of Texas. We focus not just in Central Texas, but also on the Texas-Mexican border. So our work focuses on very interesting ethnocentric enclaves in our state. We have had difficulties with patient engagement on a more macro level. And I'm wondering if any of the research that any of you have come across has identified any factors that might help improve Latino patient engagement on such a macro level? Yeah, so a lot of the research I've read up on this has been predominantly centered around addiction. But I think a lot of those principles can still apply. When we think about addiction, for example, there's been a lot of great studies that have shown increased diversity in patient population and or study recruitment by going out into the clinic to actually get those participants, right? So just anecdotally, for example, my mom works at a grocery store. It's in a very Hispanic neighborhood. And something that's very uncanny is that the police officers go to the front of this Hispanic grocery store and they stand there hanging out flyers with the idea being, we want you to see us and realize that we're not that scary. It actually drives the customers away. They're very scared of the police. But I have faith that us as a profession, we're less scary than the police. So that has been something that I have seen just personally. However, on a research scale, I have seen that, for example, we talk about substance use disorders, mobile methadone vans have done a really great job of actually reaching out to very high risk, more complex cases. So how does that look like for a behavioral service? I would say, maybe you're driving to neighborhoods and advertising your services. Maybe you're doing like, come here, we have like a private space in the community center. We have like an onsite counselor, psychiatrist, whatever may have you, who's willing to do some screening for you. I have personally done a mental health workshop where we were in the community of Newark and this was with youth, but we did have the capacity to do referrals to outpatient psychiatry services as a part of the program. So what I'm saying is, we're very used to coming into communities and offering mental health services as a first line of treatment. However, that's very scary for Latinos who have historically not engaged at any level. So what if instead of coming in and offering our services, we tag along with some of the other initiatives that are happening? For example, if there's a food pantry, if there's a community health event, you just so happen to also be there and say, and look at this, we have really great mental health support that you can do. That was my experience in working with the community, but I'm sure our other panelists may find that that's appropriate or not. Hi there, it's lovely to see all of the group here today and engage in this discussion. My specific context is I'm a second year attending at an outpatient practice at an academic center. And I see patients in Spanish and I've actually found it extremely challenging in the sense of I'm often the only person that a patient can engage with in their care who speaks Spanish. And they want me to do everything for them and they don't wanna engage with anyone else that doesn't speak Spanish. And I've been struck by, especially at an academic center, but perhaps at other settings, how it's really hard to find other members of the healthcare team, like social workers or community health workers that speak Spanish. And it's become increasingly difficult for me just because I feel like there's so much pressure on me. So I'm curious from a systems perspective, whether it's academic or not, how we think about the interdisciplinary team. I will give you my experience and I'm pretty sure we all share it in the sense that having also been the only Latino in a clinic, ultimately you have to make sure that you take care of yourself, right? Because it's gonna be, you're more apt to or open to burnout because of the fact that they'll always continue to come and they'll always be there for you. And I think that's a really important thing that they'll always continue to come and give you more and also tokenize you in a way, right? If we need someone who would have knowledge about Latino or Spanish, call on so-and-so. So take those opportunities though to educate about the importance of increasing the workforce and finding ways in which you can get involved in decision-making bodies that can actually make that happen is what I would recommend. I guess it also depends on where you are. For example, when I initially came to Orlando, basically I was in my group. Well, in my group there were other psychiatrists actually fortunately that spoke Spanish, but our population was mainly non-Hispanic or Latino. So we were the ones asked to basically talk to most of the patients that were Latino. But today that has changed completely. There's not a place in Orlando that you cannot find. You know, in the hospitals, in the community basically, almost everybody speaks Spanish these days in a way. And so it is easy for us to be able to, I guess, identify other parts of the treatment team that can speak the language. And so we get help that way. So. Yeah, I mean, it's hard. It's really hard. And I'm sorry it's happening to you. Well, I mean, and as a follow-up, I know there are plenty of other questions. I'm very lucky in my department that I have, I've never had a supervisor who didn't speak Spanish who couldn't staff in Spanish. We have very good representation amongst the physicians. But in terms of my patients who come in who have remarkable challenges in their communities, having the support around the social determinants of health and having ways that patients will actually engage because they are not using an interpreter has been more challenging. Being lucky can translate to burnout pretty quickly. And again, I think boundaries, knowing your limits, I think is important. It happens to me in residency. I was the Hispanic on my residency and it happens on the APA sometimes. When people think about Hispanic, our names come. Or we're interchangeable, right? Someone, they confuse us. There's a Hispanic guy. But you need to put boundaries sometimes, yeah. Thank you. Hi, my name's Dr. Sophia Quiroza. I am a PGY2 at a rural psychiatry residency. So I'm actually coming from a slightly different side. I am actually not from the Latino community, but I married into the Latino community, which is much in itself. But what difficulties I'm facing is that I am now the only provider for psychiatry in a very large area. And the hospital system has been very resistant to allowing me to practice in Spanish, even though they know that I am the only proficient speaking Spanish person in the area. And we have a very large immigrant community. We have large farms that employ immigrants. And so I am really the front line, and whether that's seeing somebody in the hospital for psych services or outpatient as well. So the hospital has pretty much given a blanket rule stating that the only language that can be spoken in the hospital is English. And if anybody wants to speak a different language, it must be done through their interpreting services. And as we know, the lovely interpreter is such a fantastic tool. If they can't connect or Wi-Fi's sucky or they can't hear you or again, the dialect is different. And so the hospitals actually prevented me from providing telemedicine services because there's no way to have a translator on the telemedicine services. I didn't know if you guys had maybe any suggestions or recommendations, maybe how are other hospitals, regions doing that allow providers to speak in a different language that certifies them or makes them competent? Their question is that they don't believe that there's competency, not for me, but just in general. What state? Indiana. Indiana, wow. Yeah, yeah. So, I'm not gonna disclose names because I am a medical student and I still need to match, but I've experienced this at the hospital where I've been in New Jersey. It's been quite ironic. I've been in rooms with patients who are delivering and I've been told that I cannot interpret for the woman and we're stuck with like this phone translator. It's like a weird situation. Right? I mean, it's so crazy. I'm like, they don't understand it. I'm like, I'm right here. Yeah. I'm like, you know what? Nobody can hear me, close the door. Yeah. In a past life, I was also a medical interpreter to like add to the irony and I have disclosed to members of the healthcare team, both residents and attendings and have been shot down repeatedly, which I understand from a liability perspective. Now, in terms of solutions, one of the solutions that I found is that in communicating with a company who does the interpreting services, they allowed me to take a test to basically become certified to do the interpreting. As a medical student, you know, people are still like, for liability's sake, I'd rather get the interpreter, but they offered that to me. And that wasn't like advertised like upfront. Secondly, you can, I think, advocate in your hospital to have either the hospital system, or if you are so inclined to actually become certified as a medical interpreter. Well, they don't have like a certification, which is kind of the problem because we're some like random, you know, independent standing hospital in the middle of nowhere. So they're like, we just use a random service, but I guess reaching out to the service and seeing if they would be willing to certify me or give me a test, you know, to be able to. Or seeking out your own training, which is again, expensive, but if it's a service to the hospital, I can see a world in which you can become a certified medical interpreter and the hospital might be willing to pay for it. At this point, I'm thoroughly convinced it's just liability and just, you know, bureaucracy being, you know, healthcare. But yeah, it's a universal struggle. I provide such an amazing service for our patients who, you know, don't have insurance, who are immigrants, who, you know, have substance use and I'm able to work with them and counsel them, but it's so frustrating that I'm getting, I'm the one getting set tons of boundaries for these patients who really need my help. So thank you so much. I appreciate it. We'll have time for one more question. Well, we'll take it. I want to be mindful of you guys. Whoever needs to go to the next session, please do, but yeah, we'll take the last two questions. All right, well, hello everyone. My name is Kyra Tito. I just finished my first year at Morehouse School of Medicine, so I feel like I'm fairly early on compared to everyone else here, but like others that I've spoken before, I am the only Spanish-speaking, I guess, on the healthcare team at my school's free student-run clinic. And it's primarily a primary care clinic. Me and some other students at our science chapter have actually been trying to push for more maybe behavioral health appointments at that clinic because we have physicians that are willing to do it, but I think the school, for liability reasons, doesn't want to delve into that so soon. But basically, in our primary care screenings, it's often with immigrant patients that I'm doing kind of just the basic behavioral health screening, like, oh, have you been feeling X amount of sad in the past 30 days or whatever? And they're kind of really, kind of either dismissive or don't really want to get into it, so they just kind of check no, no, no, no, no to everything. So I guess my question is more on the one-on-one basis. How do I make, or how do I help these patients be more comfortable with having that conversation in the room with me if they're just there to receive primary care services, I guess? Because in conversation, they'll mention past history of mental health disorders in their family, or they've recently felt really stressed or anxious about recent migration from their home countries. And I just want to make that conversation more comfortable for them, and I'm not really sure how to approach them without them just being like, no, I'm fine. Next question. You know what I mean? So when you have an in, basically, it's what I would say, you just expand on the question a little bit open-ended and ask them to tell you about when, if they say stress, what is it, you know, what does stress means to them? And maybe from there, you can find a way in to have them explain to you, you know, maybe symptoms and what are they feeling, and things like that, even though they might be initially reluctant to talk about it. I think if you may give them a window, you know, they will respond, patients will respond. They're probably dying to talk about, you know, what they're feeling, but it's just approaching it in the right way, and when they give you certain cues, you know, or certain words that they may use, then you can use that to open up the conversation. So for me, I was administering one of those very similar sort of depression screening tools, and the patient, before I administered the tool, told me in every single way that they were severely depressed, they were really struggling, this was like during COVID-19. And then they filled out the questionnaire, and despite my like observation, they marked like not at all for everything. And I asked the patient, I'm like, why'd you, why, like you're struggling, and the patient said, I don't feel like any of this applies to me because God has me in mind. So that's to tell you that I feel like there's a lot of work to do with the way we screen, diagnose, and proceed to treat Latino-identified patients. If you have a conversation with a patient, and you realize that they are having mental health struggles, but then the screening tool is negative, I think that is, again, your role as sort of a cultural liaison to then present to the treatment team and say, you know, patients screen negative, CIGIE caps, GAB, whatever. But also, frame it within the lens of, I had a conversation, and I'm still very concerned because these tools are limited, their reliability and validity within our population, I can't speak as to whether or not it's been shown, but that's just a caveat, and again, that's the competency and the cultural humility that I think we need to integrate in the healthcare setting. Thank you. Hello, I'm Jennifer Gao, you hear me? Yes. I'm Jennifer Gao, I'm a medical student, four-year medical student. So I want to know, I know that the new generation has, are more open to talk about mental illness, but there are still a lot of stigma, including my generation, so I want to know what are we doing to change this, because we are still in the present, we need these patients. So how can we change this mindset that says, anena, you don't have anything, tu no tienes nada, como que tu estas bien, you know, how can we change this, especially in Hispanic people? Or what are we doing beside social media? Well, we are having the conversation, that's, I mean, I think you asking the question is a way of how we're doing it, being here is a way of how we're doing it, going to a Hispanic caucus meeting at 5.30, room 21, is how we're doing it. And I think, I mean, it takes the APA 100 and something years to create a website in Spanish, that's how we're doing it. But we need people asking those questions. I mean, we are here and we all ask questions to the Assembly, GRC, Board of Trustees, because if you don't ask the questions, they will not ask the question, okay? So how we doing in the clinics? So we have clinics that are close to our communities. For example, where I work, we have three clinics and they are in the community because the people walk to the appointments. You know, we are going to where they are to talk about it, right, it's the same with recruitment. We need to be more active recruiting than passive recruitments. Passive recruitments was like putting a flyer or we're looking for someone, now active recruitment is saying, I want to stalk you on LinkedIn, right? Because I need someone like you to work with me. So those are, we need to be a little bit more proactive these days than reactive in so many ways. I also want to say that your training and the way you choose to practice with Latinos goes a long way towards changing that relationship, both on a micro and macro scale. For example, there are plenty of very famous actors, celebrities, et cetera, who have come publicly about their own mental health struggles. That's not to say that to be a good psychiatrist for Latinos, you should disclose your own mental health struggles, but you should be very judicious and think very carefully about sort of the therapeutic relationship that you have with patients, right? If I'm seeing an older Latino male who reminds me much of my father, I may be more willing to disclose that my father also has mental health struggles if I know that clinically that may incline the patient towards being more open with me and normalizing that. So I think the way you navigate these relationships goes a long way, right? Because we know that Latinos, we are very much sort of an affectionate, very personable culture, and that goes a long way. I also need to say that the way we engage, whether social media or not, I mean, Felix mentioned it earlier, but do we have shows? Do we have content? Do we have sort of mass information dissemination strategies that get to the heart of the issue, which is Latinos do not want to engage with us? So two approaches there, both of them look very different, macro and micro. I think tackling them both is impossible, but yeah, I think you can pick which one you're more passionate about and try to build upon it. Or join the Hispanic Caucus and work on the initiatives we're already doing. Thank you. Yep. All right, thank you very much. I appreciate it.

cultural competence

mental health care

Latinx community

language barriers

lack of insurance

stigma

diversity in workforce

representation in clinical trials

social determinants of health

personalized medicine

telehealth technology

patient engagement

Latinx individuals

equitable care