Latinx 2024: Beyond the social determinants of minoritized population health. How do we put it all together?-View Presentation

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Our idea is to use the first hour, we already divided the times, so that afterwards you make comments, ask questions and I want to remind you to, whoever wants to comment something, to come to the microphone.  Welcome to Latinx 2024.  So, us three and at one time with Teresa Miskiman, who is now the President-elect, we did this. I think we started in 2020 and there was a year that we didn't get accepted, so we just keep trying.  And this year we're very happy that we got accepted and, as you remember, one of the previous presidents brought to light the importance of social determinants.  And there were a lot of presentations about that, but we thought that we had to accompany that with other factors, which are not necessarily social determinants.  And the question is, how do we put it together? So, we're going to try to do that today. Renato is going to be talking more about the cultural factors, Eugenia about the psychodynamic factors, and I'll be talking about the biological factors.  So, let's see how that goes. Renato, well, there is a brief of his curriculum. As you know, he was in Mayo Clinic and also at the Universidad Peruana Cayetano Heredia.  He's Emeritus Professor there and Distinguished Emeritus Professor at Mayo Clinic, but he was also in the University of Alabama and Emory.  He was the General Secretary of the World Association of Cultural Psychiatry, and something that I really admire him for is that he's been in the DSM Steering Committee for years and been instrumental in the personality disorders work group.  I'll be presenting each one of us first, and then we're going to start, okay?  So, he's author of almost 300 publications, including books and book chapters, and he's a recipient of the APA Simon Bolivar Award, George Tarjan Award, World Association of Cultural Psychiatry Wing Song Tong Award, and how do you pronounce the last one, Gene?  Garabe.  Garabe, okay. I had the same difficulty presenting him on Saturday, but anyway, so his interests include personality disorders, mood disorders, PTSD, psychiatric diagnosis, and of course, the cultural factors.  This is me.  I'll be the second presenter.  I'm currently the President of the Mexican Consortium of Neuropsychopharmacology.  I'm a Lifetime Distinguished Fellow of the APA, like all of us are, right?  Eugenio, you also are, right?  We have the gray hairs to prove it.  The gray hairs to prove it.  All that means is we've been around that long.  I had the honor to preside the American Society of Hispanic Psychiatry and the Asociación Psiquiatrica Mexicana.  And Eugenio is going to be talking to us at the end.  I asked him, send me your bio, and he said, just put what my signature is on my emails.  He's a professor of psychiatry and public health in the Herbert Wertheim College of Medicine at Florida International University.  Well, with that, let's get started.  Good afternoon.  Muy buenas tardes.  It is my pleasure to share this session with two distinguished friends, dialect friends, who I've known for many years, Bernardo and Eugenio.  And to share with you some ideas related to a topic that undoubtedly is gaining ground day by day in the field of mental health and psychiatry.  With particular emphasis on some ethnic or cultural groups, sociocultural groups, including, of course, the Latinx population.  This is the title, which is quite general, of my presentation.  And let me, first of all, mention the points of the agenda, which I will go through very quickly.  Some definitions and conceptualizations, but basically the names of the areas that need definition, and which I'm sure you all do know quite well.  Then talk specifically about the social determinants of mental health.  And focus on the U.S. Hispanic or Latinx population, with mention of a historical involvement, socio-demographic characteristics, and the topic of mental health and psychopathology in this particular population.  Culture and psychiatric diagnosis is the next point.  And then some comments about Latinx psychiatry as such, particularly focusing on clinical and research areas, to finish with discussion and conclusions.  So, about the essential definitions and conceptualizations, as I said, I am only going to mention them because I'm sure that not only you know them, but because time would be consuming in trying to define each one of them.  But these are the essential concepts that we deal with when talking about social determinants of mental health and cultural aspects of mental health.  Culture, race, ethnicity, context, meaning, identity, and a number of other relevant conceptualizations.  As I said, I am not going to define each one of them. Perhaps we could add a number of them.  For instance, it comes to my mind, something I talked about the other day in the distinguished psychiatrist lecture, otherness, and similar concepts.  It is important to remark concepts such as culture and ethnicity, race, racism, and racialization.  These are important concepts, if you wish some clarification later.  Racialization, as I mentioned the other day also, is a relatively new concept, but it is the result of a habit, the habit of many people, including mental health professionals, to label some community and social groups with specific adjectives.  One of them being a racial group, and that includes, of course, the so-called Latinx population.  It is important to recognize the concept of minorities and, of course, the prevalence of mental health problems in these groups.  Those are, as I said, relevant conceptualizations.  Now, let's talk about the social determinants of mental health, a global vision, and you see there, the first one that shows up is corruption.  That, perhaps, may be considered one of the latest social determinants that is added to this global vision.  In a political frame, this concept emerges as a strong determinant, so that's why it shows up first.  However, the global vision of social determinants of mental health include economic, financial aspects, and the really predominant concept of poverty.  Urbanization levels, homelessness, employment or unemployment, labor, work status, education, and the penal system.  This is a global vision. There are many other groups of factors, conditions.  You can see there is a socio-ecological nature with significant and powerful impact, each one of them on mental health at all levels and in all regions.  The social determinants of mental health, according to the WHO and the Gulbenkian Foundation, summarize a series of principles and actions aimed at a positive management of the social determinants of mental health.  A sort of what to do to make them useful and productive.  First of all, we have the need to look for a healthy mind-body system.  A proportional universalism. We know what universalism is, and I say proportional because the ethnic group or whatever we call it, the Latinx population, has its own characteristics.  And its level of universalism, that is, sharing characteristics with all other types of groups and communities of different parts of the world, it also keeps its own.  So the universalism is proportional, but as important as that is the fact that each group retains a number of characteristics.  Then, of course, another principle is the prioritization of mental health. Mental health equity and presence in all health policies.  The avoidance of the short-termism. This speaks for itself.  Many times, people in positions of authority, governments, etc., take positions for the moment, for the short-term.  And by doing that, it distracts the community, distracts the population, and ends up just being limited to that short-term. There is no long-term vision.  So principles and actions, of course, include a focus on the life course. Not only on specific points, but to look at a specific period, for instance, in the evolution of human groups, but keeping in mind that that step is only part of a whole course.  The need for early and precocious interventions in dealing with the negative impacts of some social determinants of mental health. This, by the way, implies that the social determinants are not always damaging. That's important.  There has to be familiarity with and knowledge of local level actions of any measure that is taken, and, of course, that in connection with national strategies.  The social determinants of mental health keep a multi-level framework, but I am going to individualize the one I mentioned as a very important determinant in many segments of the Latinx population and, needless to say, in many Latin American populations.  Poverty. Poverty and mental health. It is unquestionable that we all know about the association between poverty and mental illness.  The causes of this association remain unclear. Of course, we talk about the etiopathogenic nature of these factors, but also we may recognize biogenetic, biophysiological factors and, as important as that, the role of income inequality.  And then, as you can see, the factors here, beginning with poverty and all its implications of economic deprivation, low education and unemployment, results in a high prevalence of mental and behavioral disorders, lack of care, and a more severe course due to a variety of factors.  The economic impact of these problems, together with the original poverty, of course, increased health expenditures, loss of jobs, and reduced productivity.  This is just one little diagram of the impact of poverty and the dynamics of this impact on mental health and mental illness.  With this in mind, the Lancet series, I'm sure you all know about the Lancet series on mental health, published in the decade of 2010 on, was a gigantic series of studies and articles about mental health at the global level.  It is important to recognize what this report has to say about poverty and mental illness.  First of all, the term poverty as part of the social causation hypothesis, that is, conditions of poverty increase the risk of mental illness through heightened stress, social exclusion, decreased social capital, which is, as you know, human resources.  Malnutrition and increased obstetric risks, and as important as that, violence and trauma.  Versus the social selection or social drift hypothesis. People with mental illness are at increased risk of drifting into or remaining in poverty through increased health expenditures, reduced productivity, stigma, and loss of employment and associated earnings.  What is important here? The recognition of a distinction. The social causation hypothesis implies poverty as an etiological agent, etiological factor.  Whereas the social selection or social drift hypothesis implies the pathogenesis or the pathogenic, the process. So, clearly, etiology on the top and pathogenesis at the bottom imply the two ways in which poverty impacts mental health.  There are a number of, let's say, sociodemographic financial aspects of the Latinx population that I am not going to elaborate exhaustively.  And I will mention that before talking about this topic here. We know that, as of July 2020, there were more than 62 million of Hispanics or Latinx people in the U.S.  That is about 18% of the total U.S. population. Then, the projections for, say, 2060 will be 111.6 million. That is 31% of the U.S. population.  There are a number of states with a Hispanic population—eight states, as a matter of fact—with a Hispanic population of one million or more. And there are others that are growing unstoppably.  The state with the largest Hispanic population—you know, California—14.7 million. The median age among Latinos, the oldest median age, is Florida, with the age of 46.5.  And the youngest, California, 33.4 years old. There are other characteristics that have to do with occupational history and economic status that we'll elaborate more.  The so-called social attitudes towards mental illness are important, but I will move quickly there.  Thank you.  Somebody can help.  In the meantime, just to mention, the social attitudes towards mental illness is another important area in the social management of mental illness.  And we have here the cultural dressing of the stigma phenomenon. That is interesting because the impact of a higher public knowledge of neurobiology  accentuates the stigmatization process. That is important.  Then, of course, there are prejudice and inequities in the management of mental health problems in poor or minority populations.  Less disposition to interact on the professional side. That is important. Many professionals, mental health professionals, have difficulties or, in fact, unwillingness  to deal with poor patients. Clinical uncertainty associated with the perception and interpretation of the symptoms described by the patient and stereotypes in the behavior  of a poor patient about his or her health problems. Another factor has to do with the cultural considerations of disease among the Latinx patients. Multiple causal attributions.  Variant thresholds of tolerance and distress. Frequent symptoms in emotional stress cases. Somatization, agitation, dissociation, conversive manifestations, et cetera.  The themes of stigma, prejudice, and discrimination are well known. And finally, for you, the cultural syndromes and idioms of distress. This is important to know and recognize  when we are dealing with Latinx patients who show behaviors that many people would rapidly identify as mental illness symptoms, when, in fact, they are not.  As I said before, we need to keep in mind these concepts of cultural syndromes and idioms of distress that include entities peculiar characteristic of some ethnic groups  among the Latino groups. We have nervios, susto, ataque de nervios, et cetera. We have also cultural explanations that may have to do with religious factors,  social factors, interpersonal difficulties like envy or hatred as, quote unquote, causal factors of some behaviors.  The implications of the social determinants in mental health in Latinx populations, we have poverty and mental health, self-reinforcing factors, violence and corruption,  the social attitudes, the barriers against mental health care that I have talked about several times, the need of consistent mental health policies,  recommendations from international organizations, and the need of systematic research programs. All of this leads us to, and I'm going  to finish soon, about a clinically indispensable cultural component of every type of evaluation. That is, a systematic cultural clinical evaluation must be integral.  That is, to encompass all the relevant cultural factors. Exhaustive to explore these factors in depth. Standardized, reproducible in diverse scenarios and populations.  Skill-based, the provider's competence must be based on his or her clinical skills, not on his or her identity. Person-centered, it must start with the individual patient  or person, not with the clinician's assumptions about proceeding group identities. Very important. And finally, the evaluation must be educational.  That is, must be able to identify gaps in cultural competence capabilities.  The mental health services to Hispanic and Latinx populations include availability and access and utilization. The availability, you have here ambulatory services almost absent.  Direct relationship with socioeconomic variables, we have said that. Alcohol and drug abuse care, low availability and delayed attention.  Only 22% of Latinx patients with psychosis receive some care. Puerto Ricans have higher possibilities of care. That does not mean that they have the best.  Inverse relationships between educational level and use of services. Then access and utilization, low levels, limited use of services.  It's interesting that almost 70% of Mexican immigrants in community samples studied do not utilize health services. 50% of Hispanic or Latinx show less probabilities  to use mental health services. And the reasons, no use of English, living in rural zones, cultural factors, shame, doubts, social exclusion, et cetera, et cetera.  Let me just show this very quickly, the topics of potential research areas for Latinx psychiatry and the topics for clinical and cultural focus.  Biocultural correlates, clinical dimensions, placebo effects in Hispanics. These are areas of research. It's a call for clinicians and researchers  to focus on these points, on these areas, in order to advance our knowledge about mental health among Latinx. Needless to say, the crucial importance  of the cultural component in every type of diagnostic evaluation or clinical encounter is evident, and much more so among Latinx patients. The contextual, eco-social perspective  in each and all mental disorders, the use of well-proved and effective additional instruments. There are questionnaires and scales that is important to know and to use.  And active exchange of pertinent information and collaborative international research. This is extremely important. Finally, the need to balance precision, clarity, and ethics  in all psychiatric nomenclatures and classifications. Role and significance of diagnostic manual in the world. We know this very much. DSM, ICD, RDC, or RDOC, et cetera.  Advantages, disadvantages, and needs. The emphasis, the varying orientation, and important innovations in all these approaches. And the vicissitudes of psychiatric diagnosis  as a topic in urgent needs of clinical study and systematic research across the world and within the Latinx population. Thank you very much, and sorry for the length.  All right. Thank you. Yeah, that's fine.  OK. So you know, Renato, when you said that the more neurobiological knowledge, the more stigma, really, I hope we can clarify that,  because I thought it would go the other way, at least in the Latino population, where mental illness, if it's more body-related, may be more acceptable than.  We'll get to that in discussion. OK? All right. So I'm going to talk about the biological factors, and I have no disclosures for this presentation. General aspects.  OK, so the first thing is that what I'm going to present neither is exclusive to Latinos, nor does it happen in all Latinos. But there's biological factors that  are very much present in the Latino population. But that doesn't mean everybody does it, and it doesn't mean only Hispanics have it. So we talked about culture, psychodynamics.  Eugenia is going to talk about the social determinants. We already heard about it. And I'm going to focus more on the biological and genetics, but they're all intertwined.  And that was the heart in this presentation. How do we put it all together? So hopefully, in the discussion, we can get to that. So I start with stigma, specifically,  because, well, that's the belief that one should be responsible for their own mental health. That's frequent among Latinos. And that's one of the reasons you don't go seek help.  And also, the association that being psychotic equals danger. And we know it's not true. Most of our patients that are in the schizophrenic or psychotic spectrum are not dangerous.  And they are, many times, to themselves rather than to others. And hard to identify depressive symptoms. And this is a very interesting study. I'll be talking a lot about diabetes  and how it's easier to identify depression. It's easier to identify diabetes. But it's hardly suspected that patients with diabetes can also get depressed.  OK, so with that in mind, I wanted to start with this slide from 2016, that one third of the population in this country is either overweight or obese.  And Hispanics are ahead of all the other ethnic groups, unfortunately. And there are many reasons for that, among others. And this is where the social and the biological  start to collide, right? So there are obesogenic environments that impact disadvantaged populations more than others. And unfortunately, a lot of our Latino populations  live in disadvantaged environments, which are obesogenic. And there are many reasons for that. But the important thing here is, from a biological point of view, is  that this increases cardiovascular disease risk and also that of diabetes. Oops, what happened? OK, and I'm highlighting physical activity because that's my thing.  I'll be telling you about that as we move forward. OK, we're going to start with children. Behavioral risk factor surveillance system. Review of over 200,000 cases.  How does exposure or ACEs, Adverse Childhood Experiences, impacts on the manifestation and response to treatment of mental illness in adult life?  And unfortunately, Hispanics, we're, as you see, 1.8 is the OR. So I'm not going to get into why and where we know about that, unfortunately. But that translates into, or what  are we talking when we say ACEs? Most common is emotional abuse, parental separation and divorce, and use of substances in the household.  And those are all more common among Latino patients. So this very interesting study on Latinos about the telomere length and how these social factors  impact in an epigenetic manner and the telomere length. And how children of women with MDD are more likely to have ODD. And this was this very interesting study  that was more present in Latino families.  This study about autistic spectrum study, it turns out that there's a higher prevalence of overweight in this population. And unfortunately, Latinos, the predictors for obesity  include being of Hispanic or Latino origin. And that one is one of those things where my experience has been. And of course, I'm not like Renato,  who studies all these sociocultural factors. That when there is an understanding on the parents, there is something more biological like autism.  They feel less stigma about seeking help. That has been my experience. But this underlying factor of obesity is not addressed. It's considered more of a yes, biological, something  that is a neurodevelopmental disorder, but not to think that obesity could make it worse. OK, very quickly, that was in children. We're going to move on to adults.  Diabetes and severe mental illness, these were cases. Well, I don't know what's happening there.  OK, so what they did is study patients with poorly controlled diabetes. 21%, one in every five patients with diabetes, poorly controlled, have severe mental illness.  And check this out. 80% are of a minority group. So if you look at it the other way around, being a person with severe mental illness, the risk is 1.2 of also having diabetes.  And that's regardless of them being on antipsychotics or not. Then diabetes and depression, those homes with low income, the risk of diabetes and depression is 4.5.  Cannabis, I love that one.  Well, I don't really love it, but it's a big issue. I work in a rural area, and adolescents before, it's funny. I tell them like, OK, so depressed, whatever.  OK, first visit, we need to run some blood tests. You already told me you're not using substances. But we're going to get a urine dark screen just  to have it in your chart that you're not using. And even in a rural area where it's sort of isolated, Imperial County has like eight cities.  And there is 30, 40 miles in between them. Public transportation is very poor. But oh my god, cell phones are great. You just text, and it's delivered to your door.  They don't ask how old you are, really. And it's unfortunate. But OK, a lot of studies on psychosis and cannabis, I'm not even going to talk that much about it.  But when you start seeing the combination of adverse childhood experience, depression, and cannabis use, especially in women, Hispanics, they're  highly represented, almost half in this study. And check this out. If you had prior levels of depression, there is less likelihood to use cannabis.  But if there is more use of cannabis, there is a higher risk of depression. Cannabis without ACEs, more risk of depression. And cannabis with ACEs, less risk of depression.  So that last finding is very controversial, right? Because you would say, no, well, more use. Well, no, it turns out this speaks for how many people are treating their depression  with cannabis instead of seeking help to get treated like we think is better, right? But this is a trajectory that drives you, for those who are vulnerable, into developing  psychotic disorders, right? So it may improve the depressive symptoms, but it puts you at higher risk for psychosis. OK, alcohol and cannabis co-use.  Hispanics, again, top of the list, unfortunately. Here we are with all these possible factors of co-use with alcohol and other psychiatric symptomatology  and problems with functioning. And something very surprising, more are women than men. And this is a study on emerging adults.  So that speaks for the stigma and the delay on getting help. OK, finally, in the same study, on older adults, not emerging adults, but 30 to 80, the average were 52.8.  And again, more women than men. And about 60% were non-Hispanic whites. OK, so co-users was associated. What were the higher risks or higher prevalence?  Those who were male, young, Hispanic, again, using social network composition and alcohol use-related problems. OK, this is going to be the last one in adults.  Sleep, you know how we have a problem with especially emerging adults and adolescents about their screen time and not sleeping well because of that.  Well, it would seem as if in Hispanic young adults, that keeps on happening. And this is a very complex study about sleep habits and also these polygenic risk scores.  And it's a longitudinal study, very interesting, and they found the following. In Hispanics or Latinos with history of insomnia, they had lower global cognitive function  as they enter the older adult life and a higher risk for MCI. Those that live with higher sleepiness or daytime sleepiness had a higher risk of MCI.  And those with higher sleep duration have less risk of MCI. So sleep well, okay? And finally, we're gonna get with older adults.  I spoke a little bit about this on the other session that we had on Alzheimer's and cognitive disorders.  There is a trajectory which is different, appears to be different in Latinos compared to other ethnicities. Latinos apparently start with metabolic factors,  again, diabetes and hyperlipidemia. That predisposes to inflammation and that predisposes to the amyloid threshold. But the cognitive decline starts from here,  even before you accumulate amyloid,  even on patients that end up diagnosed with Alzheimer's disease. It is suggested that non-Hispanic white, they start with the inflammation and then the amyloid threshold  because the metabolic factor is not as present and the cognitive decline will begin here. And I was presenting a study, I'm not gonna present here,  where when you do imaging studies, there's more atrophy on the non-Hispanic whites because they start on this trajectory, then on the Hispanics,  but they have on their psychological testing already the same amount of deficit. And finally, with the African-American, they probably start with the metabolic markers  because after, so the greatest prevalence of diabetes is on the Native American, then Latino-Hispanic, then African-American, and then non-Hispanic whites.  Okay, and of course, there's all these,  what word were you using? The dressing, right, of sociocultural factors around that. There are a lot of sociocultural reasons why these trajectories happen in that way.  Okay, so as far as the percentage of people  living with Alzheimer's disease, this is in the 64 to 74, 75 to 84, and 85 and older, we see that Latinos, as we move up, they have the greater prevalence  of cognitive deficit as we age. And yes, the Hispanic paradox is that we live longer, but unfortunately, with more cognitive deficits,  with more degree of dependence on our family members or on some kind of caregiver. So what can we do? Okay, this is a meta-analysis  not specifically on Hispanic or Latino population,  but about how do you take care of patients with diabetes and depression coexistence. If you wanna take a message from my presentation today, it's about that comorbidity.  Diabetes is very prevalent among Latinos, and depression frequently goes unnoticed or undiagnosed. So there are a list of interventions here.  The most important one is collaborative care. I'm not gonna get into what that is. Most of you know what it is. And it definitely favored the treatment.  This one is psychotherapy alone works, not with such a strong outcome as collaborative treatment,  but it works. Pharmacological alone works actually very similar to psychotherapy and not as much as collaborative treatment as well.  And then there are others that didn't do so well. And this is, for example, one of them was a phone call, or phone follow-up was not that good. And then exercise is somewhere here.  Yes. And it's right this one, exercise. And it touches on the placebo side, but I wanna bring that up because it really works. When it works, it really works.  The difficulty is people adhering to that, okay? But if you are able to convince and keep people engaged in that kind of treatment, they can do very well, okay?  And this is a very cool algorithm for this meta-analysis and treatment recommendations, right? I'm gonna move here because I don't see well from there. Okay, so the first one is,  if you have diabetes without comorbid depression  and the H1AC is elevated,  the meta-analysis showed that group-based therapy worked. If the hemoglobin A1C is normal, then you just monitor.  When there is comorbid subthreshold depression with an elevated H1C, psychotherapy to address both depression and glycemic control showed that it worked.  And when it is within target, even psychotherapy online works, okay? Now, if you have comorbid MDD based on scales like Renato was recommending that they should be used  and the hemoglobin A1C is elevated, definitely pharmacotherapy, and they found the sertraline, agomelatin, fluoxetine, citalopram, and metformin could be used, okay?  This is very interesting because it puts it at the same level as using an antidepressant. You could use either or. So I think this is a door for us psychiatrists  to be thinking and to be knowledgeable and comfortable about prescribing medications like this, right? Well, then you have the ones that have the hemoglobin A1C  in target, group-based therapy, online treatment, and exercise could work, okay? Finally, comorbid MDD and multi-morbidity.  When the hemoglobin A1C is elevated, definitely collaborative treatment is very hard to do it any different. And if it's in target, even phone treatment showed some results. Whoa.  God, I walked you through that one. Thank you for listening. Okay, so what else can we do? This is a study on prevention of diabetes through enhancing the literacy on food, right?  And food choices. So most participants were women. Really, really worked. This is a review of 12 studies. Eight were randomized controlled trials, and four were uncontrolled.  The outcome was that in nine of them, the participants lost weight, and in two of them, their fasting blood glucose improved. What was the problem? High attrition.  So the treatment works, but how do you keep the participants engaged, right?  Something very similar, but with adolescents, well, nine to 15 years old. Again, 15 studies. It was focused on lifestyle measures. It works. Three of them. Decreases the BMI.  Even the BMI Z-score. I'm not gonna go into that, but the study is very complex. And also decreased fasting blood sugar. So I think we are physicians,  and we should be able to talk about this to our patients, right? How do we prescribe it? That's interesting. So this is what I've done. Okay, this is my humble contribution to this.  I see a lot of patients every day, and it's hard, you know, I tell them to work out, and most of them are in one platform of social media.  So what I decided to do in 2022, as we were emerging from the pandemic, I was very worried about how sedentary we had become. So I started this Project DS,  this Project Defeating Sedentarism. So what I do is that I almost every day, the first year was every day, but since then, attrition, right?  So I post the video where I'm working out, okay?  And I tell my patients, do you have Facebook or do you have Instagram? And then right there, I tell them to find me. And of course, I get more followers.  I hope I get more followers today. And I do it in English and Spanish, right? And it's so gratifying when they come back and tell me, you know, I've been working out more regularly.  And I don't only post myself working out, but I give a message, right? You know, the brain, it was presented in the study that if you walk so many minutes, or you use your bicycle,  you're gonna be less depressed, or you're gonna be less psychotic. It's amazing how many studies are on that. There's even one on suicidal ideation with hiking, right?  And what they found is that because the hiking is done in groups, it reduces suicidal ideation very quickly. Anyway, so I'm on all these platforms,  and my name in those platforms is this one, DR from Dr. Bernardo Ng. Okay, I think that's the end of it.  So Hispanic and Latinos represent an important share of the population in this country. Biological and genetic factors interact with social and psychodynamic factors,  which we're gonna hear in a moment, in the development and manifestation of mental illness. The diabetes-depression diet requires a specific approach. I spent a lot of time on that  because I think it's very, very common. And evidence supports preventive measures may improve prognosis in the long run. We need to start early. Thank you.  Well, first of all, I wanted to thank Dr. Bernardo Ng for inviting me and for having the privilege of presenting with Professor Alarcon, and I wanted to, I guess, make you aware  that the recipient of this year's Bolivar Award happens to be Dr. Bernardo Ng, and his presentation is going to be on Wednesday at 10.30.  I'm sure he'll make an announcement, so. Yes.  Okay, well, thank you very much for your patience, and the only conflicts I have is I get meager royalties from Oxford University Press.  If you wanna make money, don't write academic books. That's not the way to make money.  So here are the largest groups of immigrants in the United States. As you can see, Mexicans as a group are the largest individual group, and then there's a mixture of others,  and some of the Latin American countries are highly represented. The Dominican Republic, where I come from, even though it's a very small country,  is highly represented, especially here in New York, and these are the states with the most foreign-born population. The darker ones, you can see, have larger immigrant populations,  and as Dr. Alarcón mentioned, California is number one, and this is very important. Who makes more money out of all the immigrant groups?  Indian Americans have a high social capital. A lot of professionals from India and Pakistan immigrate, so they arrive in the United States with very high social capital,  and they are welcomed to the jobs that are very high-earning jobs, and then you see the list going down, and the average American is about 2 3rds down the list,  and not to get too much into political issues, but you wonder about xenophobia and anti-immigrant sentiments  and maybe this chart gives you a little bit of information where you can draw some conclusions. So from the beginning of time,  human beings have migrated. We started here in what is modern-day Tanzania and moved all over the world looking for better opportunities, and these are the type of immigrants,  at least the ones that arrive here in the United States, mainly the financial immigrant, then the intellectual and professional student immigrants, some of us are represented here,  the refugees, the exiles, and the migrant workers who have the most difficult time.  Very important when we're dealing with refugees, immigrants, exiles,  there are three fundamental questions that we have to ask of the immigrant. Under what circumstances did they arrive? Was it voluntary or forced?  And did they come here as a conqueror or as a slave? It's a little bit exaggerated, but I guess it's self-explanatory. Is there a structural ceiling  beyond which the immigrant cannot advance in spite of their talents and efforts? And is there an ethos or stereotype from which the immigrant cannot separate  in spite of the fact that the stereotype doesn't fit?  Rumbot and Portes, or Portes and Rumbot have talked very much about segmented acculturation, and it refers to the fact that depending  on which part of the United States the immigrant arrives,  the experience can be dramatically different. It's not the same to arrive as a Hispanic immigrant in Minnesota than it would be to arrive in Southern California  or South Florida, some of the gateway states.  What talents and resources, what capital, social capital the immigrant brings, and do they go to a rural, which is usually somewhat closed, or urban, usually more open-minded  and pluralistic area of the United States? And that determines a lot of how the acculturation goes. So sometimes when we hear about the literature  on immigrants, there are these one-size-fits-all solutions  immigrants have to be given short-term psychotherapy with practical solutions. Well, you know, it's not that simple. I think we have to take into account Maslow's pyramid.  And so the more educated, the better off financially  the immigrant is, the more the immigrant is going to be able to do more self-actualization, self-reflection, and go more in-depth into transcendence  and psychotherapy of a more psychodynamic nature. So let's begin with children.  Identity is a reciprocal concept, so we defined ourselves as an individual, but the group has to mirror back that identity.  And sometimes when the immigrant has an identity in their country of origin, and they arrive in the host country, and the host country treats the immigrant  with a devalued and denigrated concept, then that could lead to ethnic self-hate, where the immigrant may incorporate the negative appreciations of the immigrant,  and then that turns into a self-devaluation.  Identity development, according to developmental studies, begins at about three to four years old, where children become aware of language utilizations.  The Honduran nanny that speaks to the child in Spanish, and the American mother that speaks to the child in English, the child can already tell the differences  between three to four years old. And then later, as they move into latency, which starts, according to Piaget, around seven, they develop a sense of ethnic orientation,  they identify with a particular social group, and they're very curious about other groups different from themselves. This has a lot of relevance with interracial adoptions,  because it complicates matters.  So, after World War II,  the baby boomers began forming a middle class, and some of the former underprivileged classes in the United States started moving into the middle class,  and so that created all kinds of dynamics,  and also in the second part of the 20th century, a large number of immigrants from Latin America began to arrive. So when we look at identity, identity is multidimensional,  there's a cultural identity, do I identify with the culture of Hispanics? Then we have our own personal identity, how we define ourselves, and then our ethnic identity,  solidarity with the group of our ethnicity. So when we look at the dynamics between parents and children, parents give children very powerful messages  about how the child is going to adapt or receive the judgments placed upon the child  by the host culture. So for example, the message that the parent gives the child can promote pride or shame in one's heritage.  And for example, in Miami, we have a large Haitian population. The Haitians are the first free country in the world of black people, they were the first black country  in the world that obtained independence, they have a very, very memorable history, and yet they are the poorest of all the Afro-Caribbean. So Haitian adolescents in Miami  prefer to be identified as African Americans than Haitian Americans because there's a hierarchy within the Afro-Caribbean groups in Miami and so they hide their ethnicity  whereas when Haitians reach the professional class they actually promote and show their ethnicity so there's a difference of associations there and so  sometimes the your ethnicity can be an advantage socially in the receiving culture and sometimes it's a disadvantage so people choose to either  present their ethnicity or to hide it depending on how it works out for them so for example a countries where blacks are a majority they have a very good  self-concept I think a very good example of that was Colin Powell who came from Jamaican parents and he really rose to the top and so he had a very good sense  of a you know who he was and so on but countries where blacks are a minority they have a sometimes an oppressed conceptualization of group membership  and this has nothing to do with race as much as who's on top and who is in the bottom in the social hierarchies and it can vary from country to country with  different races represented in each country these are some examples Afro-Caribbeans in Miami where I practice have a very good self-concept  and they do very well professionally and socially compared to Afro-Americans many of whom have migrated from the southern states and have been in the  country for many more generations and yet Afro-Caribbeans come in and they move very fast up the social scale the San Diego Miami study which talked about  how children identify I'm gonna jump through this but basically again if the group that the child belongs to has a high advantage for example Cubans in  Miami have they are very well represented politically and socially and economically so Cuban children are very proud to announce that they are Cuban  Americans when the group is more denigrated and oppressed children tend to hide their ethnic identity so one thing that we deal a lot with immigrant  children is the attachments and the ruptured attachments so migration destabilizes the family in a variety of ways and children are often left behind  with relatives and the journey to the US is often a fractured one the children when they migrate are never consulted hardly ever so children are suddenly  uprooted many times without a lot of preparation so in this way a Leon and Rebecca Greenberg Argentinian psychoanalysts who immigrated to Spain  because of the political situation in Argentina and have written wrote some of the early papers on the psychodynamics of migration they say that children are  always exiles so the child psychologically is really like an exile because they're forced to immigrate and nobody consults them however on the  other hand children have more plasticity they adapt faster they learn a language faster and this is a phenomenon that we see very much among Latin Hispanic  children especially in the Caribbean and the Dominican Republic where I come from it's very very common and this is the idea child fostering that the  parents go to the United States to make a better living living and leave children in the care of relatives and what happens is that the child then  develops an emotional bond with the caretaker that could be an aunt or an uncle or the grandparents and when the parents achieve financial success or  financial stability then they bring the children over to give them a better future and there's no acknowledgement about the attachment that disrupted  attachment and many times those children end up developing conduct disorders and also a substance abuse and deep down what there is is a disrupted attachment  that is not addressed and then that goes back to the Maslow hierarchy of needs in that the parents are thinking about financial stability and they're not  really they haven't yet gotten to the point where they could have the luxury  of thinking about psychological stability so when children reunite after four or five years with the parents they feel like strangers and however we have  to be careful in judging this because many Hispanics also function in an extended family network system with where the attachments older brothers and  older sisters sometimes take the role of parents and the Lisa study from the Harvard School of Education you know that shows that separations are very  long Asians have the longest separations especially from the parents and many times when children experience loss they're unable to express sorrow and  instead they express anger and this is the origin of the youth gangs and this is the work of Diego Vigil in Los Angeles and who has studied the Mexican  gangs and so sometimes the Mexican gangs provides a temporary family and a structure and some of the children are able to move out of the gang others are  killed or die of substance use and so on and so forth and so that is one of the trajectories and many children are exposed to trauma there's pre-migration  migration resettlement stress and intercurrent stress and so I'm going to move very quickly a pre-migration stress children were oftentimes come from  countries with a lot of violence then the actual transition from one country to another that has been amply written about and then there's resettlement  stress forty-five percent of the immigrant mothers have less than a high school education and one-third of immigrant children live in poverty  addressing with Dr. Alarcon mentioned earlier and then there's intercurrent stress one of the protective factors of course is the ethnic enclave in Miami  for example we have a very strong ethnic enclave which facilitates entry because there's so many actually Hispanics are a majority in Dade County and so it's  easier than to immigrate I would imagine to a this is a these mariachis were the mariachis that they're called the Mora Riaga they're a family and I showed up  with them to ask my wife to marry me they are a little bit older now that picture is from several years ago but they went to the baptism of our children  and some of our anniversary so this is the Miami ethnic enclave schools are very important one of the factors that is very important is the child having a  best friend in the same school if the child has a best friend in the same school that's a very protective factor immigrant children first and second  generation of the largest and most and fastest growing segment of the child population as you can see children in schools schools are very diverse  nowadays and this is some of the work I did the Dominican miracle in New York Dominicans immigrate to New York for an education the Dominican Republic the  education was run by the Catholic Church when the population grew Catholic Church couldn't do it anymore and then education the government couldn't afford  it so a Dominicans make incredible gains and education and in only one generation they almost become equivalent in education to the American mainstream  population and so education is very important to the immigrants is the golden dream that parents hope to give their children and by succeeding in  school the child gives back to the community the community feels proud of the child and there's a very positive dynamic there and I'm going to move  very fast here you are all very familiar with how to treat immigrant children a culturally competent evaluations we have the let me see  practice parameters for cultural competence in child and adolescent psychiatry this was the lead article of the Journal of Child and Adolescent  Psychiatry and it's all there and if you want to copy please let me know and I'll give you my email and I could send you a copy of the practice parameters because  we're pressed for time one more point the life narrative this is the work that I did in the Guantanamo Naval Base with Cuban refugees in the 1990s and this was  the depersonalization and dehumanization that the refugees felt when they were left in these camps indefinitely with no foreseeable a hope  of getting to the United States the the painter is the guy with the beard in the middle and this is called the men cots so you can see how they depersonalized  they lose their human identity and they these are the cots where they lived in the tents so the role of the narrative is a exercise in life story construction  and the writers that this a lot of the literature comes from Israel and so psychopathology is conceptualized by these investigators as life stories gone  awry especially when there's trauma and psychotherapy and creating a narrative is to repair the broken narrative so creating a narrative is a repair of the  damage and the aspect the narrative can address the specific moment of the trauma and also the entire life story this is a picture inside the Guantanamo  camps in the early 1990s and these are child narratives this is Katia who she's narrating that and children draw so this is the way that children can contribute  their narratives Katia was saying that I don't know if you can see the arrow okay so she was on a raft over here with her family they ran into another raft in  the ocean but the other raft had a dead person and they were kind of freaking out having a dead person so they didn't want to throw the body away they tied  the body to a rope so that hopefully they could get to bury the person when they got to Florida and here's the dead person and then the sharks started  circling the two rafts here's the shark and finally the Coast Guard came to rescue and you can see the Sun crying so this is a example of a child narrative  here's another one where they got rescued by a helicopter and so the most important thing about the narrative is that the new narrative gives continuity  and coherence it creates meaning it provides self-evaluation and the person grows and sees a more positive outlook with hope for the future and there are  many new immigrant narratives and finally I leave you with this message this is Richard Blanco who was the poet laureate in the second Obama  administration and he's a graduate of my institution FIU and this is part of the poem that he wrote and I'll just read it very fast or ring up groceries  as my mother did for 20 years so I could write this poem for all of us today  thank you  ok so I think we have time for a couple of questions you want to come to the mic comments questions reactions we've tried our best to put together concepts that  are usually presented separately culture social factors biological factors psychodynamic factors thank you for that drawing was very impressive  comments from anybody well while you think about it Renato so I was asking you about how neurobiology would increase stigma in  my impression is that is the opposite but can you hear me yes I think it depends on who does what namely if the neurobiological explanation or findings  are presented to professionals of course the professionals are going to be impressed and receptive to the information if it goes to a community  that is well-informed and accepts the value of scientific research and puts together findings of different areas and different origins they may also be  willing to accept it and and say okay there is an explanation for what is going on right if the population is prone to a stigmatization to labeling  to criticize to negativism or negative thinking they are going to say aha now that explains what is going on and that is something that cannot be modified  because it reflects and I'm using the reasoning okay because that reflects brain brain damage or brain problems that are unmodifiable so it is it has to  do with how the information is presented who are the recipients of the information and how the information is interpreted or received by the audience  so there are distinctions and I think that the solution to this problem is in of course increase the let's say knowledge sophistication of the overall  population to understand and interpret the findings do you want to comment on that honey no okay yeah it's just that I thought or my understanding was that  you know how when you talked about Susto in an attack in the nerves that the manifestation was more physical right people pass out or or have seizures like  symptoms and that the more physical was would justify mental or emotional symptoms that's that's where I was no the cultural concepts of distress those  three notions that are present in the SM 5 are areas to which individuals patients family relatives can resort to to be to understand better that these  are not symptoms of a mental illness these are expressions of a cultural context okay so that is part of the overall process of education not only to  professionals but also to the general public and communities that's where the difference is go ahead sir thank you please state your name and where you  come from it seems like it's off  people having had problems with a co-creation with stigma but I found very refreshing your talk dementia because the whole concept of is trying to  instill into people a sense of hope that they can do something I know there's a lot of stigma about mental illness in general but I think also medicine in  so well I have it so it's then and and I think that we need to be carriers of hope good news change in people and say yes you can do something and for it  little as it may be it is your life and you can try to enrich your life with the spite of deficit thank you  Please update us on your social personality.  Yeah, your question is very complex. I can only say it depends. If we talk about antisocial personality among Latino populations, I would say the information  is scarce. There are not too many, and I would only resort, I'm thinking of, say, books or volumes. I am thinking more of articles, kind of isolated or not  combined into a book. On the other hand, if you talk about antisocial in other communities or in general, books on personality disorders have very  illustrated or illustrative articles or chapters, and the books by authors such as Andrew Skodol, John Alden, Michael Compton. I mean, a number of authors that  we can talk about that later, but those are authors who have focused on personality disorders, have written books, entire books about it, and of  course the chapters on different areas, on different types. You can tell us, like, the newest something on antisocial and Latinos? Yeah, just a pearl. Well, there  are, and this is an interesting angle of the concept, antisocial personalities in Latino populations are mostly, and that is a cultural factor, associated  with, quotes-unquotes, delinquent behavior, and with violent behavior. Interestingly enough, similar to the interpretation of psychotic behavior among Latinos. They  are violent, you know, and so those are, the word has been used, stereotypes. So, that is one important thing. Authors that have dealt with personality disorders and  antisocial, particularly, there are not too many. I think in Latin America, Chilean authors have contributed to this. I can mention Veronica Lerach and other  authors in Chile, and in Mexico, I think also from the Institute, Mental Health Institute, they have dealt with personalities as a diagnostic type, not  as a cultural concept. Cultural concept in Mexico, we have here Sergio Villaseñor, who is an authority on cultural psychiatry, and perhaps, Sergio, sorry to  bother you, but you may contribute, the point being that the cultural perspectives on personality disorders in Latin America is a big area that needs  exploration. Okay. Eugenio, something about migration, right? Venezuela. Venezuela. The Venezuelans in Miami, definitely, there's a very, very large Venezuelan  migration to Miami. They have the advantage that they have found an ethnic enclave that is very welcoming, which was paved by the Cubans, Colombians,  Nicaraguans, and so on and so forth. So, that facilitates acculturation, but as you well pointed out, there's the mourning and the loss of the person's  professional identity, and yesterday, I took a cab here in New York, and the cab driver was from Bangladesh, and he was a university professor in Bangladesh. So,  these are the compromises of the immigrant. One comment, the Venezuelans in the Dominican Republic. I have a friend, a childhood friend, who is a senator in  the Dominican Republic, and he was telling me that there's an interesting phenomenon. There's many Venezuelan immigrants to the Dominican Republic. Now,  the government, which is now the Maduro government, many of the functionaries who have a lot of money, and they made a lot of money in the current government, have  homes in the Dominican Republic, and sometimes they end up right next door to the exiled Venezuelans who have been running away from the Maduro and Chavez  government, and this phenomenon has been very true with Haitians. Haitians in Miami sometimes end up living next door to the people who were their henchmen  and persecutors, and that lends to very difficult dynamics. One quick anecdote. I have a good Venezuelan friend I went to school with in New Jersey many years ago,  and one day, I decided to look him up. I said, I wonder where my friend Alfredo ended up with all this mess in Venezuela. So, it turned out he was living five  blocks away from me. He was a lawyer in Venezuela, and now he's training to be a realtor in Miami to sell apartments, so that is a common adaptation.  Common adaptation. Renato, go ahead. Yes. Yes, the comments and the response from Eugenio really opens up or brings up to me a very interesting detail related to  Venezuelan migration or Venezuelan migrants to Latin American countries. I just want to share that experience, that observation, which is the matter of a  series of articles. Four articles, three of which have been published, or the third one is being published, and the fourth is going to be submitted by a  group of Latin American psychiatrists from Colombia, Ecuador, and Peru, and it has to do with, I say, Venezuelan migration. What happens? The numbers are  millions of Venezuelans who have left Venezuela, a good number of them out of their own willingness. They wanted to leave a country that was going through a  crisis. Another group, people who were in jails, in prisons, delinquents, criminals, who were liberated by the government and sent out of the country to these  neighbor countries. And, yeah, back in the 70s, yes. So, then what has happened? The phenomenon is fascinating and painful. Most of the Venezuelans in those three  countries, Colombia, Ecuador, and Peru, are labeled as criminals, delinquents. No matter what their profession is, they are working in decent jobs, yet a good  number of them are labeled as criminals. And then all the delinquency acts or violent acts in Lima and other cities are attributed to Venezuelans, and the  fact is that it is not so. So, these are social, cultural variants of a phenomenon of this Venezuelan migration situation that is not the first  time that it occurs in the world, but it is a painful situation. Well, with that, we're going to have to close because I think the next group is  coming in. Thank you very much for being here. See you Wednesday at 10 o'clock, Simon Bolivar Award. Thank you.