Thank you for coming and attending today's talk, which is called Increasing Access to Evidence-Based Interventions for Common Mental Health Disorders in Underserved Communities in the United States. Today, we have Ted. I call him Ted, but his name is Dr. Thaddeus Inonacho, who is an associate professor of psychiatry at the Yale School of Medicine. Dr. Inonacho completed medical school at Abia State University in Nigeria. He then went on to complete his psychiatry training in Dublin Island, and then his residency psychiatry in New York until he made his way to Yale School of Medicine. He's also the medical director at ARERA Community Center at the VA Connecticut Health System. As you can tell, Dr. Thaddeus has so much experience working in low to middle income countries. He is also the director of the Happiness Project, which is a primary care program in Nigeria, which he will talk about a little bit more. Next slide, please. So today's webinar is funded by the Striving for Excellence Series, which is made available through SAMHSA and the African American Behavioral Health Center of Excellence. Next slide. If you're interested in obtaining any credits, there are CME credits available for today's talk and for participating, and I think there will be a survey after the end of this webinar for you to complete and obtain those CME credits. Next slide. If you're interested in the handouts, Ted has graciously provided the PDF of his slides and you could see it in your right hand box and the little PDF symbol where you can kind of download that and review it in your own time. Next slide. If you also have any questions, we'll have some time at the end of the webinar to ask Ted some questions. So please go ahead throughout the talk to add the questions in and we'll get to them at the end of the talk. Next slide. So Ted has no financial relationships or conflicts of interest to report. And without further ado, I'm going to pass it off to him so he can engage us and tell us about a lot of the work that he's been doing and how we can kind of inform the stuff that we do ourselves. Thank you so much, Duny. I really appreciate this opportunity. It's wonderful to catch up with you. Actually, this is great. Thank you for the warm introduction. And hello everyone. I'm really delighted to talk about some of the work we're doing in Nigeria and some of the work that other people have done around the world and look at how some of that can help with our goals in the United States to increase access to mental health care. The key learning objectives here for this talk today is to, you know, sort of hopefully participants will identify barriers to mental health care in underserved communities in the United States. We also hope that people can understand, you know, some of the similarities in the strategies that we've used in low and middle income countries to increase access to care. And also identify opportunities for adapting these strategies in general medical practices, psychiatric practices across the country in the United States and across different health systems. A quick outline of the talk. We want to take a quick look at the burden of and the impact of mental disorders in general across the board. We look at some issues related to access and some of the strategies for increasing access to care. We'll cite some examples, particularly the ones we have been involved in towards Nigeria and some examples in other low and middle income countries and see some of the relevance and potential strategies that are applicable in the United States. So real quick, and I do hope I'm sort of preaching to the choir here. We all know that mental disorders are quite common across the world, affecting more than 1 billion people globally. Mental disorders account for 7% of all global burden of disease as measured by DALYs, which is a measure of functioning. And also accounts for a significant amount of lives lived with disability. Depression by far the biggest contributor to disabilities and DALYs for both sexes, with slightly higher rates in women. Substance use disorders also contribute, but much more in men. The relative share of these disorders has increased in the past couple of decades, in part due to the persisting stigma around mental health issues, both at the personal individual level, community level, and system level. And I use stigma here in broad strokes because stigma means different things in different countries, and that is an entire area of study. But stigma captures some of the challenges around, you know, we talk about mental health, how we address mental health, how we treat people with mental health disorders. And then the other key element that contributes to issues around caring for people with disorders is that there are actually lack of treatment access. People don't have access to treatment. So those are the two main, in addition to other issues, these are the two main drivers of accessing care or low access to care in most parts of the world. Across different regions in the world, as you can imagine, 80% of people with mental disorders live in low and middle income countries. And by nature of the world, there's a differential impact due to stigma and discrimination, limited availability of mental health services, lack of specialist care, inequitable distribution of resources, low investment in health, and low level of legal protection around policy and legislation for people with mental disorders, and also the disproportionate impact of poverty. Now, some of these issues actually contribute to limited access to care, even in high income country like the United States, particularly in rural and underserved populations in the United States. So in general, there is a persistent gap in mental health care across the world, more so in low and middle income countries, up to 70 to 90% of people with mental illness not having treatment. And as I mentioned earlier, a major reason is lack of trained providers who have specialist knowledge around mental health. And one would wonder, so is this a problem of low and middle income countries? But actually, a lot of people who have studied this, particularly the most recent well-studied and well-documented data around the world shows that despite substantial research advantages of what is helpful in mental disorders, what can be, what can promote health, translation into real world impact has been terribly slow. And so it is really a challenge for us to take a look at all the things that we know can improve mental health for people with mental disorders, and actually for the population in general, and then take a look and see how much of that actually gets put into practice, how many people get access to this treatment. So it's really a big challenge, not just in low and middle income countries, but also in high income countries, even in the United States. And as a matter of fact, the last permission that was written up in 2018 concluded that all countries can be thought of as developing countries in the context of mental health. In other words, if you really focus on mental health, most of the challenges that are faced by people with mental disorders in low and middle income countries are similar challenges are there for people with mental disorders, but not all of them. And so it's challenges are there for people with mental disorders in high income countries like the United States. For example, this is a graph that just captures the level, the number of people with mental disorders or mental health diagnosis in the United States. If you take a look, you see that the United States is way, way up there in terms of the burden of mental disorders among high income countries. And if you dig deeper into the data in the United States, you will find out that only about one in six adults is able to get, you know, or afford health care, you know, mental health care when they're experiencing emotional distress. The U.S. also ranks high, actually has one of the highest suicide rates among 11 high income countries measured. And actually the rate has been increasing over the last 10 to 20 years. And the U.S. has a very high rate of substance use, you know, mortality from substance use disorder, which actually has gotten worse over the last year or two because of the combined impact of COVID and increasing issues around opioid use disorder. And although the United States has a lot of capacity around mental health, especially relatively speaking, compared to other parts of the developed world, the U.S. has a relatively low workforce capacity to meet the mental health needs of its population. So in other words, the United States cannot really depend completely on specialist mental health providers. That is really the key message. When you think about it, everybody agrees that mental health can be provided in primary care teams. However, including mental health providers of primary care teams is less common in the United States than in most other high income countries. And the U.S. primary care practices are among the least prepared to manage patients with mental disorders. The good news, at least one of the good news, is that there is a well-established evidence that the step care approach can reduce treatment gap. In other words, not everybody with a mental health issue need to see a psychiatrist or need to see a psychologist or need to see a specialist, a mental health specialist. Most people with mental disorders can be managed in a step care fashion. In other words, they could see somebody who doesn't necessarily have specialist training, but who's been trained to identify, screen for, and treat common disorders in the community. And as the severity of illness progresses, depending on where it's identified, for those severe mental disorders, which is difficult to manage in a community by non-specialists, then those people can be treated by psychiatric specialists. So this is a well-organized, well-documented, studied process where a step care approach to mental disorders has been shown to be effective in improving access to care and reducing treatment gap. That is one good news. The other one is that there is also evidence that staff sharing, which is basically trying to say, well, not everyone needs to see a psychiatrist, at least not right away. A lot of people who are in the care continuum can see people, starting from trained community members to peer support specialists, then to non-specialist health workers, as community and home-based nurses, all the way to nurse practitioners and physicians and psychiatrists. So these are workforce that can be distributed across the need for care. In other words, if one needs counseling, counseling can be provided by a peer specialist, for example. And so if they need to be prescribed a medication, then they can see a nurse practitioner who has psychiatric training. And then if they need to be hospitalized, maybe they need to see a psychiatrist, something like that. So staff sharing has been well-documented again and studied, particularly in the mental health area, in low and middle-income countries, to be a pathway to increasing access to care by utilizing non-specialists and sharing care, essentially, among a team of providers. So I'm going to talk a little bit about what this means practically, particularly with our work in Nigeria. I have to say there has been a lot of work around step care, staff sharing approach in mental health care around the world, from the Manas trial in India to Chile, where they did depression treatment in primary care, to Uganda, where they did community-based group therapy for substance use. So there has been a lot of, to Pakistan, where they're thinking a healthy program, utilize lay health workers in the community. So there's a lot of examples around the world of the potential impact of step care, staff sharing approach to increasing access to care effectively. But for this talk, I'm going to focus a little bit on the work we're doing in Nigeria and how we can identify key community resources that may lend themselves to both the step care and the staff sharing approach. So we look at our work with churches in Nigeria, and then our work with primary health care centers in Nigeria. So the first one is the Healthy Beginning Initiative. This was a NIH-funded project that tried to use church-based platforms for health interventions. It was originally funded for identifying pregnant women with HIV and initiating care for them to prevent mother-to-child transmission. And essentially, it utilized the baby shower framework, using baby showers, like we know baby shower within the United States. It just introduced the idea of baby shower in the churches, and using the baby showers, baby receptions to screen women for disorders, including mental health issues, and then provide education, counseling, and referral to care within the church activity of baby showers. This was actually led by clergy and trained church health advisors. So together, they introduced the program, talked to people about it, provided education, and they trained church health advisors who provided screening, identification, and referral to care, and basic psychoeducation around mental health issues. And this was a partnership with health systems and hospitals and PEPFAR, a huge PEPFAR infrastructure around HIV treatment in Nigeria. So this is just a brief outlay of the baby shower framework. So those of you who are from Nigeria, you know how Nigerians love their churches and love prayer. So we incorporated a prayer session to identify and recruit pregnant women and their male partners, which was huge. Using the baby shower as a determined, on-site, integrated screening testing, clinical assessment, and making referrals. These are all happening within the churches. And then when people come back with their babies at the six-week reception, we can focus on getting more education around health issues, testing their newborns, and then linking them to care as well if they come back with any new medical or psychiatric issue. So this was a huge success. We ended up, the study recruited 2,700 pregnant women and their partners as well. And essentially, the ransomware control trial showed that there was a huge, huge success in terms of identifying people with health issues through the churches and making connection to care, both for the HIV-positive and HIV-positive women, and also for the HIV-positive issues and other medical issues. There's quite a few papers published around this. So basically saying that the church platform in the community can be an avenue or can be a framework or a place to provide healthcare, which is not traditionally the case. People have done stuff with churches and communities, but actually you can do a lot within the church framework in the community if the support is there. And for mental health screening outcomes, we did identify about 21% of people scored above the threshold for psychological distress, depression, and anxiety. The women had higher scores than the men. And mental health screening and referral treatment is feasible. That is the main takeaway from all that we can actually screen for mental health issues in the churches and refer them to treatment. So this is something that is doable in the churches. And this was not just about the women, it was also about their male partners. Unfortunately, of those who screened positive and were referred to treatment, only about 5% of them received any further care. So which made us wonder whether we can, and we're looking at it right now, which is can we, instead of just making referrals to care, can we actually provide a treatment, the actual treatment in the churches? So we're looking to train clergy who had a very positive experience of this Healthy Beginning initiative. And most of them believe that mental health disorders are treatable. They were willing to be trained to provide therapy on the church platform. And the church has advisors who are already trained to do mental health screening and refer to treatment. Moreover, the HVR model has been adopted across multiple states in Nigeria. So we are thinking, right now we're looking at training the clergy in these churches to provide CBT for depression in the church and being able to refer women or people with more severe illness to psychiatrists. But they can at least provide most of the basic counseling and CBT treatment in the churches. So we're looking at the CBT, actually we're trying to develop a manual and we're using a mobile app as well called CBT Assist to support the CBT work by the clergy. And we want to eventually compare this pathway of care with the usual continuum of care. Well, besides the research, this has been a wonderful experience for me going back to Nigeria and initiating this project in the churches and having the community buy-in and the church buy-in and the people buy-in into basically doing mental health in churches. This has impacted the stigma. I can have a couple of papers around how this has improved the stigma around mental health by just being able to talk about it in the churches. The next project I want to talk about a little bit is the happiness project we did a little earlier. The happiness project called Health Action for Psychiatric Problems in Nigeria including epilepsy and substance use. The goal really is integrating mental health and epilepsy treatment into primary care. Essentially, we adopted the World Health Organization's MHGAP 2.0, which is a tool developed by the WHO to integrate mental health into non-psychiatric settings by training and building capacity within primary health care centers, secondary health care centers, and even tertiary health centers for those who are not psychiatric specialists. It does use the reliability of the step care task-sharing approach that I mentioned earlier. Most importantly, it is really aligned with Nigeria's national quality of mental health, which is to integrate mental health into primary care. In fact, they call mental health the ninth component of primary care in Nigeria. When I say primary care in Nigeria, primary care is really public health care in Nigeria where every community in Nigeria has a primary care center funded through the government health system, has nurses, has community health extension workers covered by doctors, for the most part. And so it is really a question of testing it out and then scaling it across the country because it's a nationwide infrastructure. So the key elements being that it leverages an existing infrastructure for sustainability and scalability, and it also builds capacity for, again, for sustainability and scalability, building capacity among people who are already employed in the health care system. We do include mobile technology only because it is really important to not think about the role of mobile technology in increasing efficiency, utilization, access to care these days. This is just a quick picture of our team in Nigeria. This was when we did our last, sorry, our refresher training in 2019 before COVID hit. So this is just a quick outline of, you know, sort of some of the engagement and recruitment we did in the phase one, done our pilot training, and now looking at doing a randomized control trial of our intervention. So the key components of the Happiness Project 1 is the training. So we adopted modules from the MHGAP, as I mentioned earlier, which is a fully validated, well-utilized WHO tool for training. We identified trainees who are mostly all primary health care teams, community health care workers, nurses, and doctors. Again, the goal is to train those who are already employed in the health care system and able to implement what they learn in actual clinical practice. The total duration of hours, about 40 hours, divided across five days was a combination of didactics and interactive workshops. Before the modules had to be adopted, and the process of adaptation include just looking at the modules, adding local examples, identifying key areas of interest in the community, and including the community in designing the modules, albeit on the basis of the original MHGAP. And we have a certification process where people have to meet a certain sort of standard, both in pre- and post-phase, but also observed session. This is just some of the pictures from the last training that we did. The other element of the training is the clinical support and supervision. So training people around how to use basic clinical screeners like the PPRS, PHQ-9, having a fairly clear, straightforward standard of operation. And having continued education, WhatsApp has been a wonderful thing about organizing people in Nigeria around a scheduled weekly chat, educational videos, and even voice messages for people who want to use voice message. So Nigerians love their WhatsApp. It's been a great tool for us to communicate, coordinate, plan, and even provide clinical support to people who are in need. We set up a specialist supervision for the trained providers, usually monthly in-person visits before COVID happened, but more so now, phone calls, and we've included a mobile telemedicine app that we're using for that at this moment. And then we have a specialty referral pathway for complex or severe cases, or even for people who are in a very critical situation. So we have a lot of support for people with complex or severe cases, or even medical issues that need to be addressed in addition to the mental health issues. One other key element that we found useful, or we found that we needed, because we had, based on our pre-engagement and needs assessment, was having a medication-revolving fund to make sure that it's consistent availability of psychotropic and anti-epileptic medication. The contents were derived from the National Medicine Formula, which is what they call the essential drug list in Nigeria. And we had to create a whole administrative process for making sure that there's a whole logistics around procurement, making sure the medications are available and accessible to the clinicians when they need it. One of the big benefits of a medication-revolving fund, at least in the Nigerian context, is having availability and affordability for basically non-counterfeit medications, because counterfeit medications are a common problem in Nigeria, unfortunately. So we've done some basic pilot data collection and evaluation. We've done some formative qualitative data collection, looking at our iterative process of taking a look and seeing what is helpful, what is not helpful, trying to make changes on the go, and identifying key stakeholder issues that we need to address as we implement the project. We can look at some clinical data outcomes and look at our process implementation. I just want to highlight that the key element of success for this Happiness Project has been really the team-building process, where we identify key faculty at Yale who are interested in global mental health, working with them to think about how to implement the project, involving psychiatric trainees and other trainees from the Yale world who are interested in global mental health. Our local partners in Imose University Children's Hospital, faculty who have been wonderful in terms of providing access to stakeholders in the community, their expertise as well. And we've had strong stakeholder engagement from the beginning with government, health departments, primary care agencies, the clinicians as well. And we've got some funding support from the Yale Global Mental Health Program, CBM International Rural Foundation, and recently the Hedge Award that we got that is funding our clinical trial right now. At the moment, we have trained 62 primary health care workers in 27 local government areas, which is really all the local government areas in Imose State, and currently present in 31 primary health care clinics across the state. Right now, every local government area in Imose State has at least two trained clinicians around mental health in the primary care clinics. And at the moment, we have close to 200 plus patients enrolled in our study. And we're currently looking at the clinical outcomes to see what has been helpful, what has not been. But politically speaking, we've done a bit of stakeholder engagement and identified areas where they felt like things were helping alignment with government policy, emphasizing stigma reduction. They thought that using public media, social media, which we did, was helpful. And the community outreach team was also something that they thought was helpful in supporting the project. One thing they did mention was doing the structural improvement to the primary health care centers, which to them would help them in terms of mental health, that is, selling mental health would be helpful if they had a good-looking primary health center. I'm not sure that we can help with that, but we did take it into consideration. So some of our basic quantitative data, like I said, 200 plus patients at this moment, mostly female, common diagnosis, psychosis and depression, some SUD, some epilepsy cases, and also the usual medical comorbidities. But surprisingly for me, quite a few cases of dementia, which wasn't in my radar as we were designing this study. So that made us think about what support we can give to people with dementia in our part of the world. So we're looking at continuing our randomized trial and looking for a larger grant to do a scale-up, both at the local level and the national level. Ultimately, we are hoping to link together these two community-based approaches to care. And this is where I think it becomes really essential to have a full buy-in from everyone in the community, government agencies, faith-based organizations. It really would take a major investment of time and resources to build a comprehensive community-based healthcare, utilizing existing community resources that are not health centers, that are not specialist centers, building up structures in the community on existing infrastructure. I think that is really the key, and that is where we are headed, hopefully. But this is where I think, if agencies can think about how to leverage community resources to improve access to care, screening, early identification, common treatments in the community, this is the key to wellness, prevention, wellness and treatment even for mental disorders. I want to do a quick shout out to the one, I'm not involved in this project, but I love it, the Friendship Bench in Zimbabwe. I have their website here. Essentially, this project, their goal is to train people in the community, trusted people in the community, mostly grandmothers, to provide counseling and psychosocial support for depression and other mental disorders in the community, for people in the community, in a very non-stigmatizing way. I just love the Friendship Bench because it's really just community-based and community-led and very organic in the way that it was developed. So usually, like I said, you use a task-sharing approach by training their health workers, in this case, grandmothers, to recognize mental illness and use locally validated assessment tools and offer evidence-based problem-solving therapy. Basically, play this Friendship Bench within clean premises, where clients can speak to these trained health workers. And they did an RCT a few years ago, which really showed that this was really an effective way to address depression in the community and with improvement maintained even after six months, compared to the control group. So I love the Friendship Bench as an approach that just captures everything that we need to do, using the self-care approach, using the task-sharing approach, and using the community resources that people are... We have a lot of people in the community who are willing to support, who are willing to help. They just need to be organized and trained and empowered to do so. That is something I think that is really, really the way to go around mental health, particularly in the United States. And I have to say, I think, I think the Friendship Bench has been adopted somewhere in New York City, I think in Brooklyn. But I have to check that out properly. But I think there's been some movement around adopting the Friendship Bench in the United States, I think somewhere in New York, which I think would be wonderful. So overall, the lessons we've learned from our work in Nigeria, some other work that have been done around the world, around the step-care, task-sharing, community-based approach is that basic mental health care can be integrated into non-medical community settings. Definitely can. Also, care can be delivered effectively by lay people when they are trained. And community-level public health agencies can help deliver basic mental health care. It doesn't have to be a hospital. It doesn't have to be a doctor's clinic. It doesn't have to be an emergency room. Particularly relevant, this is really, really relevant in low-resource settings and underprivileged settings. And when I'm thinking of the United States, I mean low-resource settings in the inner city areas, low-resource settings in communities, low-resource settings in rural communities in the United States. This can be very, very relevant. I just had a wonderful presentation from one of our faculty doing some work with Appalachian community in Tennessee. And it was amazing to see how utilization of community resources and community in itself can be very helpful and powerful. Then cultural and structural adaptations and even rethinking of Eurocentric care paradigms are important for acceptance. You gotta make things local. You gotta make things relevant. You have to have buy-in. If we go in truly with a very Eurocentric care system that we have, people are gonna reject it. And I think it's really one big lesson I've learned from our work in Nigeria. I think we need to pursue a more vigorous, this is something I've learned from our work in Nigeria, we need to pursue a more vigorous and wider utilization of basic mobile technology as a way to enhance access to all levels of care for mental disorders. So there's a lot of potential for task-shifting step care in the United States. People have been looking at this for a few decades now. A couple of papers around use of community health workers, community outreach and education, leading daily activities, specific psychotherapies, behavior activation. These are all things that can be done by community health workers. It's been shown to be effective in other medical specialties diabetes, high blood pressure. We've done a little bit in mental health, but needs to be scaled up and done more in communities. Primary health care teams as well. People have done studies, done some pilot testing around using primary health care teams to deliver medication management for depression, low intensity psychotherapies in a primary health care setting, school-based consultation. These have been done in patches. The reality is that these are not widespread practices, at least not as widespread as they can be. So there are opportunities to actually take this all in and implement it at a cross scale in the United States, particularly in places that need it the most. So I think it's important to think about how can the, what makes sense in the United States. I think there should be a focus on expanding care into everyday settings where people actually spend time. There has been people that have looked at, doing medical care in shopping malls, pharmacies and schools. These are all things that have been done in the United States and other high-income countries. But even more unconventional places and innovative and disruptive places like churches, hair salons, barber shops, these have been tried out in other medical specialists as well, like intervention for stroke, hypertension, diabetes, these have been tried out in beauty salons and churches. Less so around medical, sort of mental health issues. So we need to think about how can we deliver mental health care? How can we deliver mental health education? How can we deliver mental health screening? How can we deliver preventive mental health intervention in our everyday settings? Churches, hair salons, barber shops, malls, how can that be done in our communities? Particularly in areas where there is not enough. The other thing is, right now there's a use of mobile crisis teams for emergency psychiatric issues. So that is fairly common across many states. The question is, can we utilize the mobile crisis sort of team, and I heard the word crisis, but can we utilize these teams for non-emergency, even preventive psychiatric care, or at least non-emergency psychiatric care? But I have to say even preventive, right? Instead of going when the person is screaming and yelling and kicking walls and trying to kill someone, can families call a crisis team if they want someone to provide some basic counseling around someone struggling with school, work? Can people be supported around, when they're going through a divorce, can people be supported around, you know, mild symptoms of depression, even if it doesn't merit going to a psychiatrist. So these are things that we can think about shifting the mobile, community mobile crisis themes, which are now focused on emergency situations to less emergency and even preventive care. I just want to mention quickly, before we go into any questions that people might have, I want to mention some of the things that are going on in the country that I think are really hopeful and I'm very excited about, I'm very excited about. So the idea of, you know, providing basic mental health care in non-medical settings. My colleague and dear friend, Ayanna Jordan and Charia Bellamy are doing their Imani project in churches in New Haven. And I think they just got a nice funding to sort of test it out and try it out in most of Connecticut. But this is a church-based intervention for substance use, which essentially brings substance use treatment into the churches using community resources, training people, engaging folks in mostly black and Latinx churches. I think this is huge. This would be super impactful. It is easily scalable across communities in the United States. The focus on substance use but also other mental disorders. I know community programs that bring opioid use disorder treatment to shelters and community centers in parts of Boston. This is an example of how to move treatment from medical centers to the community to bring treatment to where people are specifically for their condition. I think that's really wonderful. I also came across MindStyles. I don't know what the status of this is, but this is really essentially in Connecticut where they leverage or sort of coordinated with hair stylists in Connecticut to provide counseling and education around mental health for people coming in to do their hair. And I think that's really something that examples of things that can be looked at or scaled up because part of the challenge is a lot of research and research and research, but really this is effective and can be scaled up easily, but it needs funding, it needs community support, it needs policy changes, which I'm going to talk about a little bit. There's also the idea of cultural and social adaptation and rethinking our Eurocentric care paradigms. One example I saw is the citizenship model of recovery, which really thinks about recovery from mental illness, not so much about treatment, but just about the five hours in which they listed our rights, roles, resources, responsibilities, and relationships, just incorporating human stuff into recovery so that it's not about illness, it's about strength, it's about participation, it's about engagement. And I think this is one way of rethinking our intervention so that it doesn't have to be medical intervention, it could be community intervention, it could be something that people relate to on an everyday basis. I do think that we need to really look at our psychiatric intervention, make it in such a way that people can accept and feel connected to it. One big headline I think is important, particularly in the United States, that everything we are saying here, nothing is going to change much if we don't address racism in our healthcare systems, and our systems in general, it's not just healthcare systems, but just our systems, which are mostly hand down from our racist past. So I do think that part of any healthcare advocacy will be to take a hard and honest look at systems of racism that are entrenched in our healthcare systems and other systems, and working on policies to address racism in healthcare, and focus on the social determinants of health to increase health equity. And also focusing on using health equity as a lens for designing, developing, and delivering care and interventions. These two elements are really where the heavy load is in terms of changing or shifting the care burden and access to care, improving access to care in the United States, addressing racism in our systems, focusing on equity as we design, develop, and deliver interventions. I also want to mention that this is just because COVID has basically brought everyone into this space where we know now that health can be delivered remotely, but we need to push more. We need to sustain the COVID-induced changes in telehealth services, but we need to address it even more. We need to look at licensing, we need to look at accreditation, we need to look at policies, we need to look at legislation. And I know I'm sounding more and more like a politician here, but I think we need to look at this if we're going to sustain some of the benefits or some of the benefits we got from COVID changes, right? Telehealth access, licensing across states, accreditation of care systems, and looking at reimbursement for telehealth services or even telephony services. I think this is really work that needs to be done. And again, I hate to be sounding like a politician here, but we, forgive me, but we need to take a hard look at how healthcare is paid for in the United States. For me, having someone who I did medical school in Nigeria, lived and worked and trained in Europe, have lived and worked and trained and worked in the United States, as long as healthcare is for profit in the United States, we're really at the beginning of change. Like we need to think about how healthcare is delivered, who pays for care, how it is paid for, or else all of these changes that need to be made is gonna be much more difficult and longer to do if healthcare is based on when people are sick, they get care. When they are not sick, they don't get any support. So that is really a big challenge. And I think if we don't think about it, if we don't make the changes that we need to make, socially and structurally and politics and legislation, is really gonna be a tough battle. So I'll leave for the next 10, 15 minutes, if there are questions or comments. Thank you very much. Thank you, Ted. That was fantastic. There are a couple of questions that I kind of wanna dive into. So the first one for you is, that when you were describing the happiness projects, it seemed as though epilepsy was lumped into mental health disorders. And can you explain the reason for why that is? Yes, so in Nigeria, epilepsy has the same burden of disease as mental disorders. In other words, there's stigma around epilepsy. People think epilepsy is caused by witches and witchcraft and curses and evil. And so in the end, most people with epilepsy actually ends up presenting to psychiatric system and psychiatry. So for that reason, psychiatry in Nigeria by default, see people with epilepsy. So one of the things that has been shown to be helpful based on WHO studies is that including epilepsy treatment in the MHGAP and primary healthcare team helps address the stigma, but also helps access to treatment without needing to see a specialist, either a psychiatrist or a neurologist. So that is a key element of why we included epilepsy in the package. I think that's good because I think you also kind of answered the next question, which was, the interaction of neurology and psychiatry. And I guess why a lot of individuals with epilepsy are seeing people or are seeing psychiatrists, especially in Nigeria. Yeah, that is really just, it is because of the community belief around epilepsy and its presentation. And so they end up going to psychiatry really. But otherwise it really is of course a neurological problem, but they end up going to the psychiatrist. And so by default, that's what happens. I don't know, right now we have one or two neurologists on our specialist team, but I don't know the actual sort of system level connection between those psychiatrists who see people with epilepsy and their neurology colleagues. I would have to take a look at that. I'm not sure what the system level connection is. So there was another question. I think it was when you were talking about collaborative care and task shifting and stepped care and the use of community health workers and primary care teams. And so the question was really, what has been the reaction of the US medical society as a result of the pandemic? And I'm not sure if you can answer that question. What has been the reaction of the US medical societies with the increased delegation of a model like this for care and whether or not that reaction has been a positive one or a negative one? And Dave, if I didn't ask that question entirely how you intended, please. Yeah. Yeah, I guess the question would be, would people accept sort of giving their jobs to people who are not, you know, to other people, I guess that's the bottom line, right? So in Nigeria, we haven't gotten a lot of pushback in Nigeria around this idea of using task shifting and stepped care approach. I think mostly because even the psychiatrists in Nigeria recommend that there's in Nigeria there are 200 million people and there are only 350 psychiatrists. So there is absolutely no way there are no psychiatrists in Nigeria. But Nigeria has the lowest ratio of psychiatrists to populations in the world. So it's, well, maybe not the lowest, but very low. So it really is not something they can fight against. But I guess in a place like the United States where you have one, again, people are paid for seeing sick people. And so your income and earning depends on how many people you see or how many people your healthcare system sees. So I can imagine where it feels like there might be a pushback if you think about this model. But think about it. Right now, we have the care systems that are based on a nurse, a nurse practitioner, a PA, a physician, then a specialist, right? So there is already that system of fact sharing and stepped care approach operating right now in our health system. The biggest challenge of that is that it's all based on hospitals. Like you have to, this is operating at a hospital, at a clinic. And so the challenge is how do we make this more common in communities? And it lies in people who are not necessarily sort of medical people. And providing care in places which are not necessarily medical centers. Because right now, our model of presenting, of providing care is really, I think, Eurocentric. And it's based on you come to the hospital or you come to the doctor's office, which is fine. Except there are people who, for multiple reasons, and that's the whole discussion. They don't have access to this care system. It is not either made for them. It is far away from them. It doesn't treat them well. It doesn't recognize their problems. It doesn't answer their, you know. So there is a lot of reasons why people don't have access to this particular care paradigm. So we need to think about shifting the care paradigm to focusing on community, focusing on community strength, focusing on community resources, and leveraging those to make care more acceptable and more available for people in the communities. But like I said, to do that, one really needs to think about a system of care, not focusing on illness and when people are acutely sick, but focusing on wellness and prevention. No, I, that was a good response to that. And I have a follow-up question to that, Ted, which is, I think that we can take a lot of the lessons learned that have been used in other countries that have been developed specific for those countries, but then we take it to a, let's just say to the United States. And so for someone that is interested in even just starting to do this type of work, how do they go about it when there seems like there's individual community neighborhoods, system level factors that all play a role into having that type of integrated care where you're trained in lay individuals in the United States? Yeah, that's a good question. I think it's the same sort of implementation process we all know about, right? So first of all, start with, like, somebody has the idea, somebody who is a champion, who is committed, who wants to do this, right? They start meeting with, you know, who are the stakeholders from the local health system to the community, folks in the community to other providers. So having the meeting, doing, you know, engagement and looking at why would people be interested in this? And so that engagement process, that needs assessment, that building partnerships and meeting with stakeholders is the same process, right? So once you get to that point, if you get enough sort of buy-in, you can then start looking at, okay, how do we do this? So it's really about, one, having the interest and having the, being a champion and then looking for, you know, people to support you and engage stakeholders and all that usual process of implementation. However, I think it needs a lot. In the United States, actually, I think there's a lot more resources. In the United States, I think it's less about resources, frankly, it's more about actually convincing people that this is doable. In Nigeria, I would say the process of engagement is around looking for resources and trying to bring it all together. In the United States, almost every resource is there. It's a question of, in our current sort of world of political divisions and community divisions even, how do you bring people to say, this is possible, we can do this? And usually when you cross that barrier, then you see that there's so many resources around that we leverage and put together. I think it's more around idea. It's really a question of convincing people that you can do things differently. I think that's the biggest challenge. Yeah, no, I think David, actually, I don't know if your full name is David, but Dave pointed out that systems of care can focus on illness or wellness and it could also be framed that they can focus on profits or health results. And he would argue that the latter is a better way to frame it because it would lead us to the mindset of prioritizing wellness, prevention, and early intervention. And I don't know about you, Ted, but I would agree with that. I just also think it's very optimistic in the world that we live in where profits do take a priority for certain systems of care. And it's not just about the bottom line of health results. And so I think thinking about it in a strategic way that speaks to people that are putting in the investments, but also speaks to individuals who actually care about their health, that is their primary concern, is important. Yeah, so I actually agree that that is how people think in general. Unfortunately, I do think that healthcare is not profitable. If you really want to keep people well, there is no profitable way to, for somebody who looking at the numbers, the money and economy, there really is no profitable way to keep people healthy because by design, if people are healthy, they don't need a lot of the health care that we need. So if you keep people healthy, it's not profitable. So I do think that that is how things are right now, but if we can think about a system that actually rewards, if we think about a system that rewards keeping people well, because right now our system doesn't necessarily, not overall, doesn't reward keeping people well. If you think of a system that rewards keeping people well really, that could be the way to think about like actual sort of focusing on the economic benefits also. But anyway, I'm not a specialist in that, but I do agree that that's how the system kind of functions right now. Yeah. No, I think that this is being really informative and really good because I think we tend to always think about what we do here in the United States and how it can apply to low to middle income countries, but we don't necessarily always think about how strategies that have been used in low to middle income countries can be applied to the US. And so I think that that is a good way of thinking about things, especially that have worked in developing countries. And so I appreciate this talk and I'm pretty sure that everybody that attended this talk today appreciates it too, Ted, and your work is just super impressive. So thank you. Thank you so much. My pleasure. Thanks. All right. There's a couple of slides after this that are a little bit more about housekeeping. Okay, so I'm going to push, yeah. And so this is going to give, for the people that attended, will give you the rundown on how to claim your CE credits or CME credits. And so I will leave this up for a little while. I don't know, is there a slide after this, Ted? Let me see. No, this is it. Okay. And so if you just follow those five steps, you'll be able to kind of claim your credits, but I wish you all a fantastic day. And on behalf of everybody, thank you again, Ted, for speaking with us today. Thank you. Thank you very much. Thanks.

Increasing Access

Underserved Communities

Dr. Thaddeus Inonacho

Community-Based Programs

Task-Shifting

Stepped-Care Approaches

MHGAP Tool

Community Resources

Wellness-Focused Approach