Welcome to Mental Health and Precautions of Migration in the Americas, part one. We're actually very, very excited to see some people in the audience, because it's Sunday at 8 a.m. We're happy that we got the, you know, within the first days when most people have already arrived. But when we learned that it was eight in the morning on a Sunday, it was a little discouraging. But here we are, we have put our minds together to present this material to you. And I have agreed with the presenters that we're gonna be brief, so that you guys can ask questions at the end of the presentation. I was told about five times to remind the audience that this presentation is audio recorded, so that everybody, presenters and audience, if you wanna ask questions, please get to the microphones. And so we make sure that it gets recorded. So I said it already, and I guess I comply with that. Okay, so in a way of introduction, it's very well known that the century has been the century of migration, from everywhere, from different areas of the world to the more affluent areas in the world. In the case of the Americas, definitely we have a lot of population coming from Central America, South America, the Caribbean, and Mexico into the United States and Canada. That's the flow, the predominant flow, but not the only one. For those who are interested, after this presentation, we're gonna have part two, where we're also gonna talk about the movements that are happening in South America. For example, the one of Venezuela to Colombia, and also of countries outside, people from countries outside of the Americas on their trajectory to come to the U.S. and Canada. So one of the very interesting things that we're going to be talking about today is that migrants are stuck in Mexico. Mexico has agreed with the United States to hold or keep some of these migrants that cannot make it into the United States or don't have the proper documentation to stay in Mexico, but that stay has become longer and longer and longer. And as you remember, there was Title 42 that just ended. So this is very interesting, because when we were preparing this talk, we didn't know that Title 42 was actually gonna end or not. Juan, well, he's gonna be talking about that, and let me not get ahead of myself. But this is a law that was based on health issues, and then it allowed the administration to quickly deny asylum to undocumented migrants. It's very interesting. I wanna bring up this article published by these three collaborators who were not psychiatrists, actually, a gynecologist, a pediatrician, and an expert in bioethics, claiming that why are you using a health law, which is Title 42, for political reasons? So it's very interesting. The title of the talk was Not in Our Name, the disingenuous use of public health as a justification for Title 42 expulsions in the era of the migrant projection protocol. So we're gonna be talking about that today. And well, this slide now has become old, right? I was preparing it in February, because it did happen that in this month, the Title 42 ended. Canada offered to take 15,000 more migrants through legal pathways, and this is to assist the United States, and Prasad from Canada is gonna talk to us about that. And a very unfortunate event in March 28th, that there was a fire in one of the shelters for migrants in Mexico, and Jacqueline is gonna be talking to you about that. So as I said, Juan Gallego from the US, he's the president of the American Society of Hispanic Psychiatry. We'll be presenting on the Hispanic immigrants in the US, the characteristics and mental health outcomes. Renuta Prasad, who is the World Psychiatric Association representative for Zone 1, and as of a few days ago, also candidate to run for president-elect of the World Psychiatric Association, will be talking to us about the immigration status as a determinant of health in Canada. And Jacqueline Cortez, my dear friend from Mexico City, who is the president of the Mexican Psychiatric Association is gonna be talking about shelters for migrants in Mexico. And we have agreed also that we're gonna be presenting in the order as how the migrants go, right? So first Mexico, and then the US, and then Canada. So with that, let me put on Jacqueline's, Dr. Cortez's presentation, and we'll get started. There you go. Thank you, Dr. Cortez. Bernardo. Well, good morning. I'm Dr. Jacqueline Cortez. I'm really very happy to be here with you. Thank you for being here in early morning. And thank you, Bernardo, for the invitation and for coordinating this symposium. But well, I'm going to talk about migration and mental health in Mexico. The southern border has become a key point for the transit of people looking for better opportunities or escaping from violent situations of poverty. Mental health in migrants is an important topic since the migration process can generate stress, anxiety, depression, post-traumatic stress disorders, and other mental health problems that affect their well-being and adaptation to the new reality. It is fundamental that mental health professionals get prepared to take care of the specific necessities of this group considering their experience and circumstances. The integration of migrant into society is complex process that requires the active participation of all social actors. It is necessary to encourage tolerance, respect, and solidarity towards the group, recognizing their input to the cultural and economic diversity of the country. Work, education, and social inclusion are some aspects that should be considered to achieve an effective and sustainable integration of migrant into society. We held in Villahermosa, Tabasco, in Mexico, a regional meeting for the MPA, Mental Health and Migration, Discovering New Paths. And it was a wonderful experience because we organized meetings in Villahermosa and we have the participation of residents and psychiatrists presented different works related to mental health in migrants. Some of the topics were psychological first aid applied to migration, child trafficking between Mexico and USA, TIRUL 42 that presented Bernardo, effects of migration of mental health, behavioral dialectic intervention on acute stress disorder, and we have the participation of a journalist. He's from the news program of Hechos A.M. in Mexico and he presented the documentary Te Oder War, Mexico, Te Oder War, because he talked about the southern border. A special mention I want to talk, to give to Adolfo Castrejon and Sofia Lopez. Sofia is here. Thank you, Sofia, for your support and your participation. She's a resident. Sometimes she's very young, but she's very enthusiastic and she collaborates excellent with me. Thank you, Sofia. And Arely Reynaga is a psychiatrist that talk about immigrants syndrome of chronic and multiple stress. Dr. Arely Reynaga talk about the shelters for migrants in Mexico and especially one in Mexico City. There migrants can rest, eat, and receive medical and psychological attention feeling like an oasis. The shelters also teach them basic skills so they can more prepared and get a job more easily when arriving in their destination. While being there, migrants receive special migratory permission to travel so they can go back to their country in 15 days, but most of them continue with the trip and don't come back. Most of these shelters are supported by organizations such as United Nations, Cafemin, and MUNI, but what goes in empowering women rather than advocating it for migrants. They also receive a flyer and a special card where they can find helpful information to consider before and during their journey. For example, before departing, it is recommended that they should tell their families the route they will take as well as if they are paying someone to help them to get through. While traveling, it is recommended to use the shelters and communicate with their families telling them about the people they met or the places they have been. After this meeting, we were more conscious of the difficulties that migrants go through while traveling. It was very wonderful. It was very exciting because everyone, we were connected with emotion that made us more emphatic when treating with migrants and that we all can help in different ways. For example, you can see the guy and he was very excited and he told us that he was really like with his heart beating very fast and soothing in her hands and he was with an emotion that he hasn't had before. After we have the opportunity to visit this shelter in Villahermosa, Tabasco, we have the opportunity to donate some waters and cokes. In our conclusions, it is hard to understand the migratory phenomenon since it is not only about following the American dreams. It's about survival. While leaving their country, migrants suffer multiple significant griefs and other stressors that might put their lives at risk. Stress is the main trigger of psychopathology. Therefore, the risk of affecting their physical and mental health is high. This growing reality motivates us to look for ways to support the people with such a high vulnerability. In Mexico, there is a network of shelters for migrants who are taken to sleep, eat and receive medical and psychological services. Some of the main objectives are to help the migrants understand the importance of taking care in their mental health, as well as to help them know their rights, such as human rights and the right to receive health care. And mostly, to accept a sick psychotherapy proactively. So, I always say that I am not alone. I have a team. And I want to say thank you to my collaborators like Dr. Sherezada Poole, Dr. Manuel Dante-Albiar. They are working every week a lot of hours to prepare whatever objectives of the Mexican Psychiatry Association. And this is my committee. Oh, sorry. This is my committee executive. My committee is Dr. Victor, Dr. Alejandro Molina, Dr. Melissa. And they are working with me. And thank you, Bernardo, because you always promote Mexico academic activities, but not just national, international student. Thank you for the invitation. Because todos somos APM. We are our MPA. Thank you very much. Thank you. Well, I would like to invite you. We are going to have our 28th National Congress Psychiatry and Social Commitment. Knowing more to help better, it is going to be in Guadalajara, Jalisco in next October from 11 to 15, 2023 in the Hard Rock Hotel in Guadalajara. I would like to be there with us. Thank you. Yes. Yes. She forgot to say that Jalisco is the land of tequila. That's also important, right? I'm sure. Guadalajara and the land of mariachi. Thank you very much, Equilina. Okay, so let me pull the slides here for our next speaker, who is Dr. Juan Gallego. So he's going to be talking about what's happening then in the United States, right? Juan, as I mentioned, he's the president of the American Society of Hispanic Psychiatry and he just had an excellent meeting last Friday. Congratulations again, Juan. You're bringing life to our society with the early career psychiatrists, young researchers, great job. Congratulations. Thank you. Well, thank you, Bernardo, for the invitation. It's a pleasure to be here early on Sunday. Hopefully, you guys already had some coffee, since you can be awake. So as Bernardo said, I'm a research psychiatrist for the most part. I have some clinical hours. But my goal has been trying to increase the representation of Hispanic in the research workforce. And so we have a society, we have a meeting that's going to be happening every year, and in which we kind of bring junior Hispanic investigators sponsored by the society, and then to get trained and mentored by senior researchers. I have nothing to disclose. And I want to get started by acknowledgments, because I know usually people are running late, and that's the last slide that people cut. So to thank Bernardo for the invitation to this talk, to Dr. Levin for also the same reason, and Dr. Sanabria for helping me with putting together this talk. So what are we going to talk about today? Well, first, we're going to talk about the characteristics of Hispanics in the USA, talk about some differences by immigration waves, reasons for immigration, talk about definitions, what's acculturation, what's the Hispanic paradox. We're going to go over some mental health outcomes of Hispanics in the USA, and talk about the underrepresentation of Hispanics in clinical trials and research studies in general. And we'll finish with some of the controversies or some of the political undertones of the talk. OK, so first of all, how many are we in the US? There are about 60 million people of Hispanics in the USA, a very large chunk. We are about 18% of the US population, right? Interestingly, in about 30 years, we're going to double. We're going to be about 120 million people in the USA. So we are pretty much the largest minority group in the USA. So watch out for us. We're going to take over. Anyway, and we are actually the youngest minority group in the USA with 27 years. Still about 3 quarters of us speak Spanish at home. And we are about 12 million households in the USA of Hispanics. Unfortunately, despite the numbers, the percentage of Hispanics that have an advanced degree is very little. It's about only 5%. And the median income, as you see, is also below our minority groups, about $40,000 per year. And a good chunk, about 25%, live below the poverty line in the USA, right? So we have lots of people here. We have lots of responsibilities of trying to improve the life of them here. Today, we're talking about the immigration waves, right? So I'm a first generation, was born outside the USA and moved here. Second generation will be my kids, and so on. So in general, predictably, the closer you are to your roots, the more pride you will be talking about your roots. So if you see in here, sorry, a little sensitive here. All right. If you look at this, you will see people who are first generation, foreign born, will talk about their roots more proudly, right? Which is expected. And the more you go into subsequent generations, they will talk less proudly about their roots, because they don't really know where they're coming from as much as the originally born, the native foreign born people. In terms of the same thing here, so the self-identification as Hispanic, if you are born outside. So when they ask me, who are you? I say, oh, I'm a Hispanic, because I was born outside. For me, it's very clear. It's not an argument. However, subsequent generations will probably have a dilemma. They ask my kids, where are you from? Well, I was born in the USA, but I look like Hispanic. So it will start creating some conflict, right? And at some point, the more generations pass, it will be much clearer that we'll feel that they are American as opposed to Hispanic. And you will see that represented here in those graphs. The reasons for immigration, that shouldn't be a surprise here, but in general, you will see that about 83%, they just want to get better opportunities to get ahead in the USA compared to the native country, right? They want to have a better environment to raise their kids, have access to health, and so on. So that is sort of the main motivator for people to move to the United States. However, there are several other reasons. You will see there are educational, political, economic reasons. Some people move to the USA because of natural disasters. Some people move to the USA for professional reasons, like me, right? So there are several reasons. But in general, we just want to be in a better shape when we move to the United States, right? That's the main reason. Importantly, though, out of the Hispanics here in the USA, about a quarter of them are here as unauthorized immigration status, right? It's a very large chunk, 25%. So imagine we are 60 million. If you divide that by four, we have about 15 million people who are actually unauthorized migrants, all right? And when you talk about how do we end up here in the US, I came by plane. I had a world visa. That, for me, was very straightforward. There was no drama here. But sometimes I think about, how about the people who actually have to pay $10,000, $20,000, then try to go to the borders, face rape, assassination, and stuff like that? You say, why don't you just take a plane and ride to the USA, like most people? But it's not that straightforward, obviously. But importantly, though, about people who are unauthorized migrants, about half of them, they arrived legally into the country. And they just became overstayers, right? They sort of, OK, well, I'm going to go back. I'm going to let my visa expire. I'm going to stick around. So about 40% or 50%, 45% are overstayers. And the rest came to the country as an unauthorized migrant from the very beginning, right? That's a very important data. So let's talk about what happens once we arrive to this country. So you probably have heard the term acculturation. Acculturation pretty much is a process in which you bring your culture. And you're now faced with a new culture. So there will be some pull and push in terms of your culture with your culture. And at the end, hopefully, there will be a successful outcome in that process, right? So you have heard about the successful acculturation. There are terms like reactive acculturation. Some people talk about deculturation, when your original culture is vanished, and then you're just a whole new culture. Actually, assimilation is an outcome of acculturation. Those who are able to fully acculturate and kind of forget their own original culture become fully assimilated to the new culture. So they're indistinguishable from somebody who is from the new culture, if you will, right? So that is something that is there. You will also see something called acculturative stress, right? Because in that process of pushing and pulling in terms of between the two cultures, that will raise tensions, that will raise stress, and that can be sometimes beneficial, but sometimes it's not beneficial and can lead to psychiatric problems or psychiatric symptoms, and we'll talk about that later. So acculturative stress, that can be sort of measured using different scales, and that's one of sort of the usual outcomes in research studies or independent variables in research studies. I've seen it many times in which I have a patient in the clinic, and it's an adult, 40s and 50 years old, and they speak some English, but maybe not much, and then it's usually the kid who is the one who acts as the actual bridge between the provider and the patient. I guess in my case not as much because I speak Spanish, but for practitioners that do not speak Spanish, they have to rely on their patient's kids to translate, to provide all this sort of information and so on. So that's why they call it the biculturation, is that will be a great target for the kids, in which they are able to absorb or integrate the original culture of the parents plus the American culture. So they become this bridge for the first-generation parents. As I said before, acculturation can lead to good and bad outcomes. So let's talk about what are the potential benefits of acculturation. So you will see that acculturation can lead to higher rates of insurance coverage, access to care, right? And because of that, they will have access to preventive services. They will be able to go for a pap smear or a cancer screening, colonoscopy, et cetera, et cetera. So that's a good thing about having a successful integration into the U.S. health system. But at the same time, interestingly, acculturation has been associated with adverse outcomes. So it seems like people who are more acculturated at some point start drinking more, start using more drugs, right? It's also associated with an increase in exercise activity. So kind of integrate with the current trends of a U.S. sort of non-Hispanic whites, right? The way I see it, they take care of themselves more, but they party harder, too. You know, it's like play hard and work hard or something like that, right? And this pattern is actually more striking in females than males, right? Females will tend to have higher rates of smoking compared to the counterparts and more alcohol use. Okay. So now we talk about the Hispanic paradox. So importantly, because yesterday I was trying to figure out how to best explain this. So acculturation is more about within Hispanics. You're comparing not acculturated or unsuccessful acculturation with successful acculturation. So that's your comparison group in your outcomes. You talk about Hispanic paradox is more about Hispanics versus non-Hispanics, right? So just to keep that in mind. So in general, what's the Hispanic paradox? The paradox is despite having lower socioeconomic status, lower educational skills, Hispanics in the U.S.A. have lower mortality rates than non-Hispanic whites. So that's the paradox. How come? Because most research studies, people who have lower socioeconomic status, they will have higher mortality rate because they cannot take care of themselves and they have poor access to care. So that is the paradox, right? So then several hypotheses have been put forth to try to explain this, right? So they said the barrio, barrio in Spanish is like a neighborhood, right? So meaning like we have a close-knit group of people that take care of themselves, right? So even though they don't have access to care, they kind of take care of each other, right? Kind of imagine like for those who are Hispanic, the chavo de locho and la vecindad, right? You kind of hang out together and take care of themselves. So that's sort of a potential impact of family and friends and health. That is also the idea of the healthy migrant effect, which means that only the healthy people, only the healthy Hispanics come to the U.S. The reason why we have lower mortality rates compared to the people who are here, right? Because I guess it requires certain health to be able to travel and go through all the pains that you have to go through to get to the U.S., right? So another theory, and the very interesting theory is the salmon bias effect. So as you may remember, salmon, the fish, they go backwards at the end of their life and go back to where they were born, right? So the salmon bias means Hispanics come to the U.S., right? And then they return at the end for retirement to their home country. So the U.S. statistics do not capture the mortality of these Hispanics because they actually die in the original countries. So that leads to a decrease in the mortality rates of Hispanics in the U.S.A. See? How cool? So there's probably a combination of all these factors, right? But still, it's a paradox. How come, in theory, we are in bad shape socioeconomically-wise, how we still do okay in terms of our mental health outcomes? Now, there's been some argument because people say, well, that may be partly true, but there are, for sure, subgroup effects. You know, definitely not all Hispanics in the world eat rice and beans and speak Spanish. We are not the same, right? Definitely, we come from different countries with different circumstances and environments, but that may explain in part sort of the differences as well. Okay. Let's see. Let's move forward. So let's talk about now the data, right? So I told you about the theories, the definition. What is the data looking like? It's not a lot of data, but certainly we can see here some data that kind of is counter the evidence against the Hispanic paradox. If you look at the depressive symptoms in Hispanics compared to non-Hispanic whites, you will see the rates are higher, and you will see in this column, the Hispanics pretty much have 1.5 the times of symptoms compared to non-Hispanic whites. When you talk about sadness, hopelessness, worthlessness, et cetera, right? And you can see the same effect for men and women, right? So that goes against the Hispanic paradox. We are more depressed in general than non-Hispanic whites. But interestingly, despite having more depressive symptoms, that does not translate into suicide rates, right? So for example, you will see the suicide rates for Hispanics are about half of non-Hispanic whites. That's for males and females, and also very interestingly, same effect happens across all age groups, and being even more striking at the younger groups at the 15 to 24 years old, right? So that's interesting, you know, how come we have twice as depressed, how we have half the suicide rate compared to non-Hispanic whites, right? Now maybe part of the barrio, sort of the family support, and all this stuff that don't let you sort of hurt yourself, because certainly if you can probably see in the clinic, my patients, when you have a Hispanic patient, the patient never comes alone. You know, the whole crowd comes in, the dad, the TIA, et cetera, et cetera. We have usually white patients, they just show up by themselves, right? And so the family involvement, it's a big difference between Hispanics and non-Hispanics, and sometimes can play in a good way, sometimes it's problematic. Sometimes the Hispanic wants some space, I see mostly patients with schizophrenia, sometimes they feel like a family, let me alone, you know, because I need my space as part of the paranoia, the personality, or the sort of the symptoms of schizophrenia, right? But in many cases, actually, it's in favor, because it's the only thing that keeps them in treatment, especially if you don't have any insight into treatment, you don't want to take meds, having the family they're pushing, it's what remains, keeps them well. And when we look at, so as I said before, subgroups of Hispanics, we may look a little bit the same, but we are not the same. So there's data comparing, for example, Puerto Ricans to Mexicans, and you will see that Puerto Ricans actually have much higher rates of depression, not only moderate depression, but also severe depression, about almost like twice the rates, right? Now you look at also groups, the effect is not so striking, maybe Central Americans versus Mexicans, it seems like they have a lower rate of depression and anxiety at the high and moderate rates. But you know, so I think the big message for me here is that we, you know, we should definitely look into subgroups, because we are definitely not the same. In terms of access to care, we spoke about this before, we definitely, there's data from SAMHSA, definitely saying that we have less access to care, that's one of the big gaps in psychiatric care in the U.S., so we receive less care and we get less psychiatric medications. You may argue, well, you can look at that in a different way, we receive less care, we have received less medication, maybe because we need less, because we are doing better, but the data about depression doesn't show that. Remember, we are actually twice as depressed as Hispanic whites, we should not be getting half of the treatment that they are getting, we should probably be getting twice the treatment, et cetera, et cetera, right? So it's a complicated measure, this is kind of a cross-sectional data, so sometimes the chicken or the egg issue, right? But in general, these are all puzzling data points. And, you know, you can probably imagine, you know, speaking Spanish is a big issue, many of our people who come to this country do not speak English, so they rely on their family, but in many cases, their family is not around how they are going to communicate to their providers. So I said, we have 60 million Hispanics in the U.S., which is like 18%, however, the number of clinicians that speak Spanish is about 8%, 6 to 8%. So we are leaving about 10% of our people who are not able to actually communicate properly with their providers, right? So yes, there are translator phones, sure, you guys work on translator phones, and it's okay, you know, definitely, it's easy if you kind of have to deal with pain, UTI, sure, you can have about any pain when you pee, but, you know, with psychiatry, it's a little bit more difficult, because you have to get into sort of nuances of language and dialogue, so it gets trickier to do a full psychiatric interview or therapy through using a translator phone, right? Talk about the transference with using a translator phone, and it gets trickier, transferring to the interpreter, so how does that work out? I don't know. So it's something to keep in mind. So this is, it is definitely clear in our symposium a couple of days ago, it feels very lonely the higher up you go in the U.S. as a provider, as a clinician, or as a researcher, the higher you go on the ladder, you still feel very lonely because you don't see people like you in your circles, right? So that is a big concern. We certainly need to increase the representation of Hispanics at all levels, clinical, educational, research, and so on. So that's sort of one of the goals of our society, to try to help build this gap, or decrease this gap as much as possible. Okay, I'm getting to the political stuff, right? So as you know, we have century and states or cities. I think you probably hear more about the century cities, but, you know, there's also century states. Obviously states have their century cities, and you will see many of them have laws or regulations that talk about that, but some of them actually do not do something about it, right? So these are, this map depicts the actually the states that do really protect people, do really actually have an, are taking care of business, right? As you can see, obviously, California, all the West Coast, and then we have some people on the East Coast. Yes, so the blue are the centuries, right? And the red is the opposite of that, right? And the other colors are somewhere in between, right? So interesting stuff, you know, the three biggest, the three states with the biggest Hispanic population are what? First, California. Okay, so it's good. If you are Hispanic, you're in California. That's great. And then it's Texas, right? And then it's New York, and then is, I forgot, Florida. If you're in Florida, I think that, as you may agree, Florida can be a tough state to be if you're Hispanic these days, for many reasons, right? And as Bernardo suggested before, unfortunately, this migration and this issue becomes political currency. This is, which makes me very unhappy about it. Now, this is, for example, as you probably heard a few couple of months ago, it's still happening. When the migrants come to Florida or to Texas, the governors decide to put them on buses or planes and ship them over to sanctuary cities or states, right? In this case, people from Venezuela that ended in Texas were put in a bus or a plane and sent to outside the house of the vice president. And it's like a, what kind of a treatment is that? You know, it's good, really? So certainly they don't care about, they don't care about them, this political currency. They just want to make a statement that we don't care about them, and they're going to put them in your face, literally speaking, right? So which is totally very upsetting. And Bernardo mentioned about Title 42. So Title 42, as Bernardo suggested, is a law that in theory is supposed to decrease the number of transmission of infectious diseases. And it was sort of enforced because of COVID-19. So the idea was, oh yeah, we don't want more immigrants in this country because we don't want to get infected with COVID-19. That is the reason, right? But you know, that's not the true reason. That's the article that was written by the three people that Bernardo mentioned. It's about, it's also political. It's trying to keep people away and use that as an excuse to keep people away from the U.S., right? Interestingly, as Bernardo pointed out, on May 11th, the Title 42 expired. So it was a big sort of a chaos and crisis. What's going to happen? Because with Title 42, what allowed the government to do in the U.S. is just to immediately kick them out of the country, right? So they kind of, they came to the U.S.A. under Title 42. They can only, they can be very fast, rapidly processed and sent back to Mexico within half hour, right? That was not proper, done before on, before Title 42. So, but Title 42 had some advantages for immigrants. One advantage was it didn't matter how many times they can come out because they can always return without consequences, right? So if you get, you got kicked out, all right, I'll try again. You get kicked out again, okay, I'll try again. And they keep trying until one day they don't get kicked out and it's a positive outcome. So the fear when the Title 42 was going to end is that that was no longer going to be the case and there will be consequences of that. So that's when, you know, in a paradoxical and interesting way, before Title 42 was going to end, the voice kind of became known between immigrants that we have to cross the border before Title 42 ends. So we have to make it, right, before it is finished. And so that's why you saw 10,000 or so migrants per day at the border, right, trying to get into the United States, right? But what's interesting is after Title 42 expired, we kind of went back to, no, no, after 42 ended, Title 8 kicked in, right? So Title 8, it is a little bit more, has repercussions about this, right? So what happens when you are, you come to the country under Title 8, then yes, you will have more, you will be processed appropriately in the U.S. They are going to kick you out in half hour and certainly you will have the possibility to apply for asylum and all that stuff, but then there are repercussions, right? You could be banned for five years to return to the U.S., right? So it can be seen as a more strict law. So that's why many people tried to cross before Title 42 expired, ended, right? So the numbers at the border right now are about half of the numbers that were before Title 42 ended. And that's one of the explanations. There are explanations. The other explanation is that the Biden government also put forth a specific process for immigrants from certain countries, right? So from Venezuela, from Cuba, from Nicaragua and Haiti. So he's trying to have them do the online thing first, kind of apply online, don't come to the border. We'll try to help you out sort of legally through the online process. And so all those people that were coming through the border are not coming through the border, right? Are now trying to get it online. So that's why partially the numbers decreased at the border, right? And the breakdown of who is coming to the border now has changed dramatically because of that, right? So you are not going to see Venezuelans now as much in the border. You will see still Mexicans, Colombians and some more Central Americans. So that's one of the reasons. The other reason that the numbers decreased after Title 42 was because the governors of Texas and Florida sent police there to try to make sure people didn't make it through the border, right? And I think Mexico also sent troops there. So that's why the numbers have been decreasing at the border. And I think there's also some talk about narcos or they're trying to make some business out of this by keeping families separated. I don't fully understand that, but that's sort of one of the reasons why that happens. All right. I guess in terms of questions, that's at the end, right? Okay. So thank you for being here this morning. Appreciate it. Thank you, Juan. Thank you. So yeah, as much as this is about mental health, it's unavoidable to see the interaction with the legal and political things that have come with this. Okay. So please, you know, get ready for your questions. And as we present our next presenter, Renuka Prasad, as I said, he's going to talk to us about the situation in Canada. And let me add, as we do this, that we're going to try to bring the whole picture for you, because just like Juan was talking about, yes, people now are not coming, not as many are coming across and they're staying in Mexico. And that is a big problem in itself because Mexican authorities and the cities that are the ones where they're staying, they're overwhelmed right now, you know, with not enough shelters, not enough services. So we're going to get into that discussion as we move forward. Renuka, come on, please. Welcome. Thank you. Thank you, Juan, and thank you, Jacqueline. That was a nice talk you guys did. So when I agreed to talk, I thought it was a little bit easier topic. I never realized when I want to talk about migration and Canada, oops, migration and Canada, actually, it is a history of Canada itself, think about it. And if you think about migration, migration is a very ancient and universal phenomenon in itself. You know, it's one of the three basic components of the population growth, the other two being the birth rate, and of course, the life rate, how long the people live, those are the two things. This, when you're talking about many kinds of immigration, we took in the context of Canada, as I said, it's nothing but the history of Canada, I had to repeat, and then I said to myself, I got 15 minutes and I can't talk about the history of Canada here now. Good. And when you really look about it, you have to go back in your time and think about it. It is not about orderly population growth at all. It came in some spurs, and it's unashamedly, it's all economically based, economically self-serving, and ethnically, racially discriminating, at least in its beginning. Okay. It has, you know, at this point, I also want to acknowledge our indigenous land where we stand as well, that in fact, in that sense, my place where I come from is from the Treaty 4. I'm literally an immigrant to the Treaty 4, believe it or not. So the immigration goes back, back, you know, back to the almost centuries, if not in the recent years. And of course, when you're talking about immigration, you know, it came, you know, when you look back, the New France in the 16th and 18th century, and then we got these loyal immigrants, you know, come the 18th and 19th century, and there were some evidences that, you know, the black came during the 18th and 19th century to Canada, I think mostly to the, nowadays what you call it, Nova Scotia, you know, and Western immigration in 19th and 20th century. And if you look at the pictures here, you know, these are all the Gaelic preservations who are coming, you know, from the from the West, and then these are the Irish immigrants coming, you know, in the 19th century. And immigration and racism is kind of an intertwined as well, believe it or not. And then this was one of the pictures they have, you know, for a Chinese immigrant, where they used to give a picture of the time in early part of the 19th century. And there's a very popular one in 1914, you know, in this was some rich, a Punjabi guy from living in Hong Kong at the time, hired a Japanese boat called Komagato and then brought this kind of a people, Sikh people, and when I say Sikh, it's the religion I'm talking about, to Vancouver. And they were not letting into the country because even though they were saying they were part of the Britain and, you know, the Commonwealth, and they were not allowed. And they stayed in the boat for more than three months before letting into the country. So this is kind of the roots where the immigrations are based. And, of course, post-war, things changed, you know, driven by the economic boom, increasing demands of labor, and, of course, that's how they opened the doors for immigration. And both in Canada, it's much more stronger, both federal and the provincial governments, as some say in it. But nonetheless, they yielded to the pressure and for particularly the human rights reform. I think you need to think the way how the human rights got evolved post-war, you know, and that got started to implicate it in our kind of immigrations too. Now, Canada has come a long, long way from a way of exclusionary immigration to embracing multiculturalism and kind of having a mosaic vision of the society, not the American way of, you know, kind of an acculturation, Americanization. There is something distinguishing about keeping that individual culture. It's still deeply ingrained. Canada is a nation of immigrants. Under 20% of the population as we stand, actually it's 24%, believe it or not, are foreign-born. That is one in four, almost. 1.3 million came in between 2016 and 2021. 36% of our physicians, 36% of our business owners, and 4% of engineers in Canada are foreign-born. And in 2021 census, 8.3 million, 23% landed immigrants and permanent residents, highest among G7. In the expectation, by 2014, or 2041, 34% of the population is supposed to have, are immigrants. That is a statistic Canada's projection. Some people say it is 39% will be. And among almost one in five immigrants, recent immigrants, are born in India, making it a leading country of birth for recent immigration to Canada. Asia, including Middle East, remains the continent of birth for most of the recent immigrants. If you look at it, this is the percentage of immigration, and it is projected by 2041. The shaded one is the area where the expected rise. And also, suppose the proportion of the people also getting migrated into Canada. And this is different parts of immigrations coming from admission category, immigrations sponsored by the family for financial reasons, and can you see the last but one is a refugee. So the refugee is still a minority, you know, not the major portion of the immigration state. And it is not, and when the people immigrate, they are not immigrated to uniformly across the country. There are certain provinces where they get migrated to. Most of them, if you look at the picture there, that is, in Quebec, Ontario and Quebec are the biggest one. Ontario, for example, in 2006, that's in the blue color, had 52.3% of the total immigrants percolated go to the Ontario province. But as by 2021, each share was dropped to 44%. The thing to think about, for example, in my home province, Saskatchewan, it was 0.7% in 2006, but now it is 3.2%. So the rest of the provinces, rest of the part of the country, Canada, are also having, opening the doors and opening immigrants coming much more, much more fastly, you know, much more ahead of the other provinces as well. So this is an interesting graph in itself, and it's got it from Statistics Canada. As you can see, the immigration from United States, which used to be in 1970s, it was 10%, it has now come down to almost 3%. And look at Asia, including Middle East, it used to be in 1970s, 12.1%, and it is now 62%. Whereas from Europe, it used to be 61%, it has now come down to 10%. And also interest in the Latin America, look at it, it's almost like a small, thin line at the bottom line. It hasn't changed that much. Of course, this picture will change with a couple of things. Number one, with the Ukrainian war, you know, the Canadian government has opened its door for the Ukrainian immigrants, so that will change. And also, as earlier, mentioned earlier, that Canada also has opened the door for some of the Mexicans to come into Canada. So that will change, but as it stands now, this is what it is. So literally speaking, when I was looking, and I was preparing for this presentation, and I was asking the employee in Canada, getting the most statistics about the Latin immigration, and he was struggling to get the information. He works for the government of Canada, starts Canada, because there are not that many around. And so that makes a huge difference in the context of what we're talking today. And I did get it, this is what I got so far. In 1970, there was less than 3,000, and in 2021, that's the latest they have available, is 580, that's 1.6%. Not much, come to think about the geographical proximity in terms of the Mexicans we're talking about, the number of people emigrating to Canada is far, far less. I think that's what it is. And we talked about immigration, but there is a big chunk comes in refugees. And United Nations has said that there are 100 million people are forcibly displaced, whether it be conflict, or persecution, human right violations, abuse, you name it. I mean, right now as we speak, the Ukrainian war, and also the Sudanese, we forget about, and we talk about Europe and America, but just the war is happening even in Africa too, and it displaces enormous number of people are getting displaced within that country or outside of that country as well. Right now, according to, this was came before the Sudanese war started, and also before the Ukraine war, I think, many of the UN, many of the refugees, according to UN, is coming from Syria, Venezuela, Afghanistan, in fact, South Sudan before, because the Sudan has two conflicts, remember, this is not the present one, the previous one too, and Myanmar. And Myanmar people, many people goes to India, that's, you know, that half of them doesn't even get recorded there. You know, thinking about it, Canada has welcomed since 1980 just over one million population of this 100 million, not that much come to think of it. And I did be able to get, this is the first we have got the refugees coming in to Canada from the Vietnam war. You know, more on the humanitarian grounds. And refugee arrivals in India also fluctuates, it is not a steady growth. It reflects on the geopolitical things, what's happening elsewhere in the world as well. There's always a complaint that, you know, from the locally, that when you people immigrate, particularly, or when they take people, refugees, you know, they become a burden to the society. There is that, and an implicit message goes on without, and that has never been made explicit, and I know that because of the human rights violations and human rights issues. But if you look at it, look at this one. Unemployment rate compared, you know, local Canadian born in Canada versus refugees. And this is, in 10 years, home ownership, Canadian born versus refugees. Pretty close, you know? And then, rate of entrepreneurship, Canadian born, look at the refugees, because that's much higher. And, you know, sense of belonging to the country. In fact, they feel more proud to be Canadian than the Canadian themselves. And looking at the, you know, certificate, diploma degrees, look at this one. And, you know, Canadian born, education-wise, they are ahead, if compared to, look at the, I always like to emphasize, look at the bachelors degree. 18%, 25%. What I'm trying to say is that the refugees, when they come, even though they have a negative attitude, they provide much more strength to the country. They bring prosperity to us. We are talking about here refugees, not even planned immigrants here. And this is the source from the United Nations Human Resource, you know, from the Stats Canada. And immigration, you realize that it is a profound, non-normative life transition, requiring extensive adaptation. So really speaking, if you think about people who are immigrating, they are, I believe, they're far more resilient than the native born, because those are the people actually immigrate to start with. Those are entrepreneurship, those who want to take risks, those who want to establish something beyond what the, you know, the local geographical area provides can actually. So, but that perception is not necessarily carried all the way through. And then, mental health, there's a topic. It really depends upon how, you know, depends upon the pre-migratory preparations, the process, post-migratory adjustment, regarding settlement, social integrations. And they are all the modifying factors. Suppose if you look at the pre-migration, they're not only the personality, the age, the gender, you know, that's a giveaway. And they also had to overcome possible vulnerabilities and traumatic events as well. And what really survives them is that the relational factors and the social and education. If you are able to, if the degree gets recognized and they're socially accepted, they're far more able to assimilate and they're far more able to be productive to the society. And the migration itself, you know, that is a loss, that is a bereavement, and there is also, depending upon the circumstances, there is also a lot of PTSD if you're coming as a refugee. Once again, language, education, expectations, they all plays into part in the way how the mental illness presents itself. Post-cultural shock, we already talked about some kind of a, you know, a-culturalization. There is a question of assimilation and also de-culture. There are all some positive and negative things about that as well. And that really depends upon how fast they can be able to achieve after they've migrated into a new country, new environment, what did they achieve? And what are they able to, you know, how they're accepted in terms of it, you know, and how they're isolated or how much they're able to, mingling within their local community makes a huge difference in terms of their success. So this is, this published in, you know, 2017 by the AJP, and how this migration is trying to influence both pre, during, and post as well. Acceptance seems to be the most important factor. And Canadian Community Health Survey, it's a national survey, they linked to the longitudinal, you know, immigration database. And they found out that immigration, especially refugees, are less likely to report higher mental health issues. They're talking about in general, you're not, no segregating any group. But these differences appears, you know, disappears. There are so many theories behind that. Maybe when they newly come, they don't want to project them as vulnerable. They want to be stronger, they want to overcome, I think they overcome those kind of things in terms of an adjustment. Once they know what is accepted, then it is easy for them to accept what it is. Of course, in Canada, we have got three classes of immigrants, that is refugees, economic class, and then family class, you know, that's what it is, economy. For example, when I came to Canada, I became as an, in terms of economic class, because I was offered a job there. So my family came as a family class, that's what it is. Refugees more, have more emotional problems. That is understandable, too, because of the very process they had to go through, what they had to go through. By fourth year, you know, they, even by the end of the fourth year, 29% of them still have emotional problems. Because, remember, refugee status is something imposed upon them. It is not that they're planned towards emigrate, or, you know, immigrate. It is suddenly something forced upon them. So there is a lot of changes happens within them, too. And, of course, we already touched base here. Regional variation does exist. You know, South and Central Americans, you know, more likely to report emotional problems. In fact, South Asians, that is from India, you know, that part of the world, they are more likely to have emotional problems than the North Americans, but the presentation tends to be different, too. Generally, it is considered that when you think about the recent immigrants population, the psychological problems of them, if they are, they are associated with the low income, both before and after the immigration. And so, if they are higher income from the host country, and also higher income in the immigrant country, their emotional problems are less pronounced. But this distinction disappears within second generations, though. And so, Mental Health Commission of Canada, you know, they came up with an idea because of this kind of an immigrant. This all happened in 2008, 2009, after this post-Syrian war and everything. So, question about how to identify the need, and how do we respond as a society, and how we can able to have a national plan for that, and also, you know, looking at how do we get to implement that. Remember, that Canada is a society in which a confederate model, each provinces has its own right. So, just because they moved, come to Canada, this is not a uniform policy. It depends upon where you land, how you land. And there is also, there is uniqueness about Quebec, to many of the information I have, I don't have Quebec at all, because they have got, they work in a different parameter as such. So, and the language, because there's a bigger issue there of the language requirement as well. So, but nonetheless, coming up with this Mental Health Commission in 2009, came up with this one project, funded by the federal government. And of course, Canadian Mental Health Association in Toronto took up this lead, and called it as an Immigrant and the Refugee Mental Health Project. And this one, they started off the project with a whole idea was to how do we able to, minimize, how are we able to support the new immigrants, and to have a better physical and mental health. And, you know, and so they're at a higher risk, that we all know, but they tend to get worse and with time when they stay in Canada. So, the important thing is that how are we able to access and even provide the service. So, the issue was, how do we do that and to gain online resources? So, this is for both for the mental health workers, both for the social workers, all the point of contact, so that we sensitize the people who are getting in contact with the immigrants, so that way they can able to get all the necessary information. More or less similar way what Jacqueline was talking about in that line, but it's a little bit much more robust and much more exhaustive in approach, that's what it is. So, they need to have the appropriate and adequate information, and the timely information. And the reason why this came about is that they're recognizing that the need for immigration is very critical for Canada, that's number one, and they bring in the prosperity. And so to do that, we need to be able to help them much sooner than what they did in the previous generation. I think that's the bottom line. And so, Canadian Psychiatric Association is also developing a policy. It's actually, I'm in the public policy committee, it's under review, it is not fully published yet. So, it is only on the principles I'm going to talk about. As a policy, CPA is proposing that we need to provide access to all public service for migrant to same extent for the Canadian, in terms of the language and how do we approach them, that's the most important. We can't just say only English and French. We need to have different language, Chinese, Punjabi, Hindi, whatever the language it needs to be. It needs to be that much more adaptable too. And should be aware of the, this is the one important thing. Media loves sending the negative issues, and that causes a more negative repercussions. So, our policy is that should be aware of the impact of public portal of mental health of migrants adhering to the anti-racism and anti-xenophobic guidelines, so that way they don't, okay. And then, refugee determinations and policy also, that also need to, in a clinical practice, how do we to have, to provide them a continuum of care to have a professional interpreters and culturally safe, true, mindful care for the people with refugees and with migrants. And also, we are focusing on our educational training program to have that kind of an exposure, because remember, one in four population is going to be immigrant or refugee, so technically, 25% of your practice is going to be immigrant, and you need to be sensitized to how do you recognize and how do you address it. That is what our policy says. And of course, funding for research for the future. You know, priorities, evaluation, implementing research, how, what kind of health model is going to be useful in terms of, you know, for the immigrants. So, this has been an interesting one, too, in the sense, after the door has been opened, suggested three principles, that is, to meet the healthcare needs of the Canadian migrants, to prevent and treat the emotional distress, and this is where the sticky point is. There is no single government agency. There are multiple agencies. And you know, in a democratic country, when it becomes everybody's problem, suddenly it becomes nobody's problem, so that is always the problem, that is one of the way, that is one of the struggles Canada is still going through with it. I don't have an answer for that, but that is the way the system is. And we've got to remember this one, this is a social, you know, how do we improve the resilience among the immigrants and the refugees, their well-being, including the social capitalism and psychological, the coping strategies. How do we enhance that? That would actually will help you with improving the well-being of the immigrants, and which in turn will be helpful to the society as a whole. Canada has come a long, long way when you look at the history, but has a long way to – and still has a long way to go in addressing new migrants in their integration and well-being. Personally, I am an immigrant, I went to the UK and then came to Canada. I can honestly say that being as an immigrant, with the time and force, there are some hurdles, don't get me wrong, life is full of hurdles, but nonetheless, we were able to progress and we were able to flourish. I think I can honestly say Canada is doing at least the best it could do. Not that it can't do any more, certainly there is room for improvement, there always will be, but I think I'm proud to say that we are moving in the right direction. Thank you. So I'm going to ask all the presenters to please join me here at the podium, and of course, guys, those who have questions, please come to the microphones and – wow, go ahead. I suddenly feel like we should all go to Canada, right? Please say your name and where you're from and go ahead with your question. Thank you so much for your talk. My name is Manuel Faria, I am from Venezuela, I'm currently a student at Stanford, so super excited to be here. Also, my family immigrated three times through different countries, so love the topic. So I have two questions, mostly for Dr. Gallego, but anyone that feels inclined to opine, please do so. The first one has to do with the risk of psychosis and schizophrenia amongst migrant and refugee populations. There have been many studies suggesting that it is a leading factor, in fact, I think it's the second leading risk factor, at least in Germany. So I'm wondering if that's something that you see in Hispanic populations, either clinically or in the research at all. And the second one has to do with the fact that a lot of this research has been conducted mostly in European countries and a little bit in the U.S., and there is a difference on whether you immigrate to a wealthier nation or to a developed country, and I think that's important because most refugees are actually in developing countries. Most refugees in the world are in Turkey, and the second leading country is Colombia because they harvest so many Venezuelans. So why do you think this different context of immigration may affect differently the mental health consequences of immigrants and their risk for schizophrenia? Oh, easy question. Yeah, and I have all the answers, for sure. So when I was reviewing the literature specifically about psychosis for this talk, it was striking to see that there's actually no data, very little data about this. There was a recent paper that looked at the impact of acculturative stress in psychotic-like experiences, and they did show some effect in terms of the higher your acculturative stress, the higher the incidence of psychotic-like experiences, specifically, it comes and goes, right? It's got a little, I don't know, hiccups, I don't know. So yeah, the higher the acculturative stress, the higher the presence of voices, not of delusions, right? But they did not look at the comparison group between, you know, refugees or healthy controls or anything like that. So certainly there is evidence that the higher the stress, and you can call the stress coming from many different angles, immigration, refugee status, the higher the chances of having a psychotic episode, right? But the hardcore data in the U.S. is not there to actually say otherwise or support that. So we need to do more research, because there's nothing about that, very little about that. And I guess that probably takes care of both questions, because, you know, they kind of are both along the same continuum, right? But is that, did I answer your question, more or less? Yeah. I'm just wondering also if you have any... Microphone, microphone, please. Microphone. Microphone. Oh, sorry. I guess, just on the second question, like, how do you think, just perhaps experientially your thoughts, how immigrating to a Western nation may be different from immigrating to a developing country? Because it seems that the effects are different, at least from what I've been able to read. The challenge here is, let's say you immigrate to the U.S., first world country, but then depends on where you immigrate. So you're a Hispanic, you may end up going to sort of Jackson Heights, and then you may end up sort of in a Hispanic community. So it sometimes may feel a little bit like you're still in your own country, right? Even though you are in a first world country, and then you may not have access to care, you may not have all the support. So you may not be better off from the access to care or health insurance perspective. You may have a psychiatry that doesn't speak Spanish, so you may not be in good shape. So it's a complicated answer, and especially psychosis is such a complicated outcome, right? So it's a polygenic disease, it's not just genes, it's not just environment, it's interactions, it's substance use effects. So it's a very long equation with many different variables that will be hard to give a definite answer. But I think that certainly at the individual level, the more support you have, the better chances to have, not to have a psychotic episode. And I think substance use is a big one, right? If you have very high exposure to substance use, and depending where you are from or where you're landing, I think the chances of a psychotic episode is much higher. Thank you. Another question. Thank you. Go ahead. So I have a few questions, but I'm going to ask two so I can leave space for other people, and then if we have time, I may ask one more. So my name is Verena Rizk, as mentioned earlier, I am from Canada, or I live in Canada, I'm Sudanese-Egyptian. And I want to thank you all for sharing your knowledge with us today. I do feel a need to just share that I think in Canada, we do a really good job at welcoming people. But there's a difference between being welcoming and being hospitable. And being what? Being hospitable. Hospital. So I can welcome you into my home, but you could still feel like a stranger, right? So we could have all the signage we want. But until I put the work in to make you feel home, you're likely not going to feel like you're home. So I feel like we all have work individually still to do in that regard. But we have come a long way. My first question is about the suicide rate that you mentioned with Hispanic people who are migrants. Do you think that's affiliated with a religious ideation? That's a very good question. I don't have the answer based on data, but I think it's a good assumption. It's very likely multifactorial, and the sense of community that many times is tied to the religious aspect, going to church as a family on Sundays, a sense of integration. I think maybe have a protecting role, yes. Yeah, let me jump in here. Social research, like from Margarita Alegria, did show familialism and religion may actually cause other problems, but actually has been identified as protective factors for suicide. Okay, thank you. My second question would be for you as well, with the increased risk for substance use with people who are Hispanic migrants, who are cultured, you mentioned. Do you feel like that's because they're inheriting aspects of the culture they live in, or do you think there's also a factor? Because when you are a first-generation immigrant, or you are a migrant who has assimilated, you can also be outcasted from your community and shamed by your community if you are seen as abandoning your own culture. So do you think the increased risk for substance use is because of the culture that they now live in, or do you think there's a contributing factor of shame from the culture from the country in which they've left? Yeah, I think the question is sort of more about coming from the original culture or more attributed to the new culture. In a way, the data has shown that the longer you live in the U.S., the higher the rates of substance use and alcohol. So it seems to be more associated with the arriving culture. I'm sure if you have a family that is sort of accusing you of being Americanized or kind of ostracizing you, that will also play a role in the potential increased substance use rates. But I think it also has to do with the environmental exposure, right? There are kids that are doing drugs and drinking, and now you want to fit in with the new pals and with the new friends. So you may feel you have the peer pressure, you want to be part of the group, right? That's my sense, but the data shows the longer you live in the U.S., the higher the chance of you getting hooked to medication, drugs, or alcohol. Come to the microphone, please, to ask a question. State your name and where you come from. My name is Areej. I'm originally Middle Eastern from Saudi Arabia, and I work in Washington State. And I see a lot of refugees from Syria and Iraq, mainly, and other also refugees from different countries. But as I speak Arabic, as my first language is Arabic. So I feel that also the rate, and just tell me what you think about that, the rate of diagnosis of schizophrenia is higher among refugees if they are diagnosed by people who are not really aware culturally of what's happened in the other country or the way how people struggle, like dictatorship and also war. And then they start to medicate them with a lot of multiple antipsychotics, unfortunately, for years. And I see that often. I inherited a lot of patients who were actually treated by other physicians who I think they did not really dig deep in that person, like history, trauma history. And I don't know, what do you think about that? Do you see that often, too? Those are very good points. I think, first of all, the first thought that came to mind when you mentioned about refugees is also the incidence of probably history of trauma, right? Because, you know, trauma and psychosis come together. You have more trauma, more chances of having a psychotic episode. So I think probably you have a rich sample that are prone to psychosis compared to immigrants who don't have history of trauma. So it makes all the sense. The other thing is diagnostically, for sure, you may be able to capture what the other ones are not able to capture, right? And your important thing is, I remember reading an article from, I think it was Renato Alarcon, talk about putative versus real psychotic. Sometimes in our culture, there's a lot of magical thinking, a lot of, you know, that kind of believe in ghosts and spirits as not a psychotic episode, but as part of a cultural representation that can be mistaken by psychosis for people who are not aware of the culture. So the diagnostics sort of rates may change based on who's doing the interview. But that's also critical in that story, right? So, but I think in my practice, I see trauma, I see schizophrenia, but I don't see clearly a higher rate in my practice. But I don't treat refugees. So I think that's probably a key in the people that you see. Yeah. Unfortunately, I feel like that also increase the risk of morbidity, you know, if you are like really not aware of what happened to that person because you did, you know, some like wrongly, and then you start to put them multiple medication, which I think they could work, they could be better and okay without these medications, you know, just like to, they need some, I think some providers need to be educated more related to what happened to refugees, you know, and just why this person may hear that voices or think that dictator like are following them or sending them messages, you know. The other thing, just like following her question related to the suicide rate among Latinos and among Arabs too, you know, it is usually lower than other people when the reason said like it's religious, but I think sometimes that's my thought as maybe, and I don't know what do you think if that's like, I mean, logical or reasonable, it's also part of it may be some of the societies, they are ashamed of suicide. So maybe there are some people who actually committed suicide, but it's not reported as a suicide. They try to hide it, and I actually, I was in San Diego and I tried to do a research related to suicide among Arabs or in Middle Eastern people, and it was very hard for me to find data, you know, and there was like really a lot of biases, like for example, in Syria zero, which is impossible, right? In Sudan, which is especially like it was higher, and I think that's because UN, like United Nations was very involved during, you know, and that's why maybe they were digging deeper, but like in all like Arab countries, the suicide rate is low. I think, yeah, religion can play a role, but I think also like there are a lot of people who commit suicide and because there is high depression and they are not reported as suicide. Yeah, that's a very good point. I think religion, to go back to the religion piece, you know, most of the Latinos are sort of Christian, Catholics, right, and that culture, you know, they believe if you kill yourself, you go to hell, right? If you think that, you know, even if I wanted to, I don't want to kill myself because I want to end up in hell. So I think that probably is a protective factor for suicide, but I'm sure there is also underreporting maybe because of they want to be ostracized by families, or the family doesn't want to acknowledge their kid that also killed themselves, it can be also hiding under the rug. But I think if I have to guess, probably more of the first one, I think religion is a protective factor. There are indeed lower suicidal rates, and I think it's because of the fear of the repercussions culturally and religiously. I think Muslims are the same way, like they have this, the same thing, like if they will kill yourself, you will go to the hell, so the same idea. But I think sometimes also, like, the pressure of religion, like, hey, you don't have to go to psychiatrist, you go to mosque, you go to church, you know? Oh, definitely. That's why I said it may be causing other problems, but not necessarily kill themselves. And I have to add, and Jacqueline, you may be able to help with this, in Mexico, being such a religious country, too, we have an area in the south, around Tabasco and Chiapas and Yucatan, where the suicide rate is higher than in the rest of the country. And they're not even, they're not any less religious, and they're finding there may be some genetic factors, actually, predisposing to that. So the story is very complex, and while I was mentioning about religion, that it may protect you against suicide, it doesn't protect you against other manifestations of mental illness, necessarily. In fact, as you said, maybe a hurdle or a barrier for some people to seek help, because of the same thing. We're about to run out of time, so are there any other questions? If not, go ahead, Renuka. Yeah. I was about to respond to your first question about psychosis among the refugees. My first and foremost is that the definition of the psychopathology itself needs to be clarified within the context of it, because in the refugees, there are so many, you know, trauma they have based it, and sometimes the diagnosis becomes very challenging. To say that psychosis or schizophrenia becomes an unheard, there is not much of a clear-cut evidence that the refugees have a higher incidence of schizophrenia, period. That's one thing. They are subjected, of course, to PTSD. Of course, there are situational psychosis that can happen, but there is no evidence to say schizophrenia. Yeah. Yeah. Yeah, another important point is that the way the conceptualization, I think we touched upon it. I can quote some of my own clinical examples, how people coming from South Sudanese, for example, how they presented themselves when they're practicing something, you know, putting some, they're going out almost naked in minus 30 degrees to put something outside of their apartment to put the evils not to come into the house, and that's why they ended up in the psychiatric ward, okay? And it was literally, that was the way they practiced at home, because her child was ill, so it was thought to be psychotic, but you know, when you really sit down and talk, it was not a psychosis, that's the way they cope. You need to think about those things, too, how they get kind of documented. That's number one. Yeah. Symptoms are symptoms, but patients are patients, right? So we have exactly one minute for each one of you to give a closing statement, so we're going to start in the same order that we did. So if Jacqueline go first, one minute, just last words, conclusions, then Juan, and then Renuka. I'm surprised to see this many people on a Sunday morning, at eight o'clock, that was what I'm... Yeah, yeah, well, but hold on, you go last. Go ahead, Jacqueline. Well, my message is that if we learn more about this problem, we are going to be more most conscious, and I'm going to be happy that we continue to prepare ourselves about these topics, because it's different when you just watch news or program news or whatever, but when you really study it, prepare and visit, and you can see the persons you can emphasize, and you can see the human that is behind the migration topic. So it was for me an excellent opportunity to see in a different way, as a person, as a human, it's not just like a psychiatrist, this topic. Thank you. Thank you, Jacqueline. Yeah. Okay. Juan, go ahead. Your closing statement. Closing statement. Well, I guess, let's move to Canada. Let's move to Canada, I know. I'll come to Canada. Even in the hospital, we can take... Welcome. No, I think as a country, the U.S. definitely should look north, because I think there's a lot of interest from the media to portray the immigrants as bad people, and some governors don't help. But I think a lot of the strengths of the United States still come from immigration, right? So the United States has been good at recruiting the best of our talents around the world for their university, for their schools, and China has learned that very well, and they are exporting talent everywhere. So I think we should learn from Canada that taking care of immigrants should be key, educating them, giving them all the resources, and the same part that Americans, because it's only going to help the United States. So I think that would be what I think critical for the United States, and we all have a role to play in there. So I think we should, in our own institutions and practices or research studies, try to encourage that. Thank you. Juan. Ranuka, you're closing. One minute. The thing is that, as you have pointed out, we have opened the door, still we are struggling to find their role into the part of the day-to-day life. I think it is a process, and that needs to be practiced, and then we have to move it as well. It's just like, I like your analogy, you can invite your neighbor into a house, but your neighbor to be part of your house is the next step. We are still there. We are still struggling. I think we'll be there. Thank you. Thank you very much. Let's give a round of applause to this great presenter.

mental health

migration

North America

Central America

Title 42

acculturative stress

Hispanics

asylum

Canada

immigration policies

cultural competence

undocumented immigrants

healthcare access