We want to be very mindful so that we can get you out of here on time, and it's my distinct pleasure to welcome all of you for this session. My name is Raj Tempe, and I'm the chair of psychiatry at Creighton University School of Medicine and the past president of the American Association for Geriatric Psychiatry. The presenters for today's session are Dr. Pallavi Joshi, also known as Dr. PJ. She's an assistant professor of psychiatry at University of Arizona College of Medicine and Banner Alzheimer's Institute. She is the past president of PsychScience, the student organization associated with the APA, and she's the past MIT member and training board member at the American Association for Geriatric Psychiatry. With us is also Dr. Dilip Jeste, and as I always point out to everyone, Dr. Jeste is the mentor of mentors. If you don't know Dr. Jeste, you've not paid attention to what's happening in American psychiatry for the past four to five decades, so it's a great honor for us to have him here. Dr. Jeste is the director of Global Research Network on Social Determinants of Health. He's the president-elect of the World Federation of Psychotherapy. He's the former Senior Associate Dean for Healthy Aging and Senior Care and Distinguished Professor of Psychiatry and Neurosciences at UCSD. He's the past president of the American Association for Geriatric Psychiatry, past president of the American Psychiatric Association exactly 10 years ago. He is the former editor-in-chief of the American Journal of Geriatric Psychiatry, and now the editor-in-chief of International Psycho-Geriatric. So that tells you the pedigree, what Dr. Jeste brings to this talk. Erlin Lane. Erlin is a clinical research assistant working for Dr. Torres, who was supposed to be present, but unfortunately has to be in London, so Erlin has very kindly agreed to take his place. He works at the Division of Digital Psychiatry. Erlin's work has largely focused on measurements of methodological and interventions conducting prior research in developmental psychology with Dr. Nancy Budwig at Clark University. In conjunction, he was conducting research on modeling suicidal processes under Alex Miller at Harvard University. Erlin is a graduate of Clark University with high honors in psychology in 2021 and a master's in public administration in 2023. Erlin has moved into work with digital phenotyping under Dr. Torres and is exploring the capacities of smartphones to effectively measure behavior. No conflicts of interest for any of our presenters today, and the objectives of our presentation are to understand the concept of social determinants of mental health, to learn the putative mechanisms of social determinants of health for dementia. We're also going to look at putative mechanisms of social determinants of mental health for schizophrenia, and in the end, we're going to talk about understanding the use of technology in assessing and enhancing social connections. Housekeeping part for us is we will have enough time, at least about half an hour, for questions in the end, and when you're asking questions, if we can please use the microphone, because this session is being recorded. I'm going to ask Dr. Joshi to come up first for presenting her part. Thank you. Thank you, Dr. Tempe, for that wonderful introduction. My name is Pallavi Joshi. I'm a geriatric psychiatrist at Banner Alzheimer's Institute, and I'm also the associate program director of geriatric psychiatry fellowship training at University of Arizona. So it's my honor to present with Dr. Tempe and Dr. Jeste and Erlin Lane today. So I don't have any disclosures. The objectives of the first part are to understand the concept of social determinants of health as they relate to dementia, and to learn the putative mechanisms of social health for dementia, to practice the clinical assessment of social determinants of health in older adults, and finally, to understand the policy and public health implications of social determinants of health as they relate to dementia. Okay. So what are social determinants of health? There are six or seven sessions at this year's APA on this topic. So would anyone like to share what they think of or how they conceptualize social determinants of health? You can just shout it out. Don't be shy. Yeah. Excellent. Yeah. Social factors which affect health. So exactly. They are non-medical factors that influence health outcomes and have a significant effect on health inequities. They are not personal characteristics. So sex, gender, age are not social determinants of health. They are personal characteristics. Sexism, ageism, genderism, these are social determinants that both influence health outcomes and have a significant effect on health inequities. And social determinants of health are not a fixed, static, or monolithic entity. They change with time. They're fluid. They evolve. Their magnitude or presence in a person's life is not a fixed, static, or monolithic entity. They change with time. They're fluid. They evolve. Their magnitude or presence in a person's life may wax or wane with time. And finally, even though a lot of times we do discuss social determinants of health as having a negative impact on health outcomes and health inequities, they are not all adverse. Some may actually have beneficial effects on health. And we'll talk a little bit about some of these specifically as they relate to aging. So older adults with mental illnesses are impacted by several different types of social determinants. They are impacted by general social determinants of overall health and also social determinants of mental health, such as stigma against mental illness, mental health care disparities, mental health care reimbursement, specifically as it applies to older adults, a flawed criminal justice system, homelessness. These are specific additional social determinants of mental health. And finally, aging-related social determinants of mental health, which further compound and complicate this presentation. So the Global Report on Ageism defines ageism as stereotypes, prejudice, and discrimination directed towards people on the basis of their age. And it can be interpersonal. It can be individual. It can be directed on one individual to another. But they can also be institutional and systemic. So disparities in reimbursement for health care costs based on age, hiring policies that are based on age, arbitrary cutoffs for fitness to work based on age. These are all institutional and systemic policies that are ageist. And they can also be self-directed. We often think of isms, like ageism, ableism, mentalism, as being directed by one entity towards another. But they can also be self-directed, and they can negatively impact outcomes based on that. And ageism-related social determinants of health cause inequities and has detrimental effects not just on the individual, but also on the community and society. So how do we quantify the impact of ageism? A recent meta-analysis with over 7 million participants demonstrated poor health outcomes in 95.5% of studies and showed a strong association between mental health conditions and ageism. The economic impact of ageism on the annual health care costs in the United States is $63 billion. And finally, we recently all experienced the complication of existing inequities with the COVID-19 pandemic. And particularly as it relates to ageism, it highlighted the intersectionality of ageism, mentalism, and ableism. Social isolation and loneliness is an aging-related social determinant of mental health that disproportionately affects older adults. Older adults are more likely to lose family members and friends to mortality and morbidity. And there are potentially modifiable factors to alter the social isolation and loneliness, including improving quality of social relationships, low self-efficacy beliefs, and unsafe neighborhoods, which lead to increased social isolation and increased loneliness. Now, social isolation and loneliness are related but not identical or interchangeable. So, social isolation pertains to the presence of social relationships or the absence of social relationships in one's life. Somebody can be socially isolated and be lonely. Loneliness is the feeling that comes in response to feeling socially isolated. However, people can be not socially isolated. They can be in a populous neighborhood. They can be surrounded by people. They can still feel lonely if the quality of the relationships is poor. So, there is a need for better solutions for public policy, city, and environmental planning as a public health priority in order to mitigate the feelings of loneliness and social isolation. Another aging-related determinant that hits me particularly hard as a training director is the geriatric workforce shortage. So, while the number of older adults in the U.S. is expanding, the need for geriatric care is growing. At the same time, we're crippled by a gap between the need and supply of geriatric experts. Geriatric psychiatrists are retiring, and geriatric psychiatry fellowship spots are not being filled. So, we're not able to keep up with the need. And a major reason for people not going into fellowship training or extended fellowship training, part of that is poor reimbursement. Part of that is a need to pay back loans and compromising that by another year in fellowship training. There are significant care delivery issues. A lot of us have embraced telehealth in the recent years, and while telehealth has improved access to people who are far away and in rural areas, we've also anecdotally experienced that older adults and people with cognitive issues have greater difficulties accessing telehealth. Now, earlier I mentioned that there are some social determinants that are not necessarily negative. Resilience, compassion, and wisdom. These are all aging-related social determinants of mental health that positively impact health outcomes. Although older adults had a higher risk of hospitalization and death during the COVID-19 pandemic, compared to their younger cohorts, they had a significantly lower incidence of anxiety, depression, and stress. Our younger adults, our adolescents, were hit particularly hard by increasing rates of depression, suicidal ideation, and self-injurious behavior. So what can explain this discrepancy between the detrimental physical impact versus the relative lower incidence of poor mental health outcomes? A lot of this is attributed to the greater resilience. So when I was in fellowship, I had a 103-year-old patient, and he was in an assisted living facility. He was very socially isolated because the assisted living had stopped all the group activities. There were weekly bingos, communal meals. Somebody would set a tray outside his door and knock and leave, and he wasn't getting any social interaction. He's 103, so even his children were in their 70s. His children were also vulnerable to the pandemic. And he said that sometimes I just go out and I just stand there hoping I'll accidentally run into someone. I'm so lonely. And he was like, Doctor, I don't know how old you are, but you're not 103. And 103 is very old. And I was like, well, thank you for noticing. But I'm not 103, and I don't know what it's like to be 103. But I also don't know what it's like to be 83 or 93, but you do. So you must have gone through other challenges in your life. What did you do? How did you handle them? And he said, well, in World War II, and I thought this was a historical anecdote or like a war story, but he said, in World War II, I was a squadron leader. I was like, oh, my God, I've only read about it as a historical event, but he's experienced World War II because he's 103. And he's like, well, I was a squadron leader, and my troops, their morale was flagging. So I started leading Shabbos services at night, and we had to be creative because we had to have blackouts. We couldn't light the candles like we were supposed to, so we had to be creative and work around it. But I worked around it, and I started leading the Shabbos services, and my troops' morale grew from that. And I was like, well, World War II was not great. It was pretty bad. So if you got through World War II, you can get through this. And so he has a reservoir of experience and resilience. These are the kind of things our older patients have experienced. They've experienced great adversity in their lives. They've experienced significant personal losses. A lot of them have been in times of war, in times of economic crises, in times of other health care epidemics and pandemics. So they're able to use their own lived experience in order to guide their current experience. That is the resilience that is a protective factor for this demographic. But what is wisdom? Well, wisdom, as it relates to this discussion, is a very specific entity. It's a collection of prosocial behaviors, including empathy, compassion, altruism, and a sense of fairness. It requires decisiveness or ability to make timely or effective decisions, and a general knowledge of life and social decision-making and spirituality. There's an acceptance of uncertainty or divergent perspectives. And finally, this wisdom is associated with well-being, happiness, life satisfaction, and resilience. So during the COVID pandemic, for example, there was a lot of uncertainty. There was a lot of ambiguity. There was a need to make decisions based on very little information. And people who had more wisdom were able to navigate that better. I'm going to talk a little bit about putative mechanisms of social determinants of mental health, bearing in mind the time and, you know, set it up for an introduction for Dr. Jesty's coming talk. So there is a social gradient to social determinants of mental health. In that individuals with lower social status have greater health risks and lower life expectancy than those with higher status. And these inequalities are cumulative. So the life course trajectories are influenced by earlier and accumulated inequalities. So for example, somebody who's born into a lower socioeconomic household, starting from the beginning, may have poorer access to high-quality food, high-quality education. Down the line, may have poorer employment opportunities, may have poorer income, which intensifies these themselves. And then we know that poor education, poor socioeconomic status, poor nutrition is downstream associated with a higher risk of Alzheimer's disease. So this is an example of how just one inequity in the beginning of life can shape the entire life course and over time be cumulative. And the onset, duration, and magnitude of exposures affects the long-term health outcomes. So here is, I know the gray text is really hard to read, so we're not even going to try. But this just encapsulates the nature of the cumulative nature of the inequities and how they all interrelate. So for example, this shows how low quality of education, shorter years of education, leads to a difference in the type of occupation. And that has an impact on the socioeconomic positions in one's life, the cognition in daily life. And those combine to impact health care and health disparities. Again, this is, again, another visual representation of the cumulative nature of social determinants of health. You know, here it starts in the prenatal period, but I would argue it starts even earlier because the impact of social inequities alters the DNA. And so it generationally alters the DNA and the genetic information. And so somebody whose mother experienced significant adverse events, their mother's DNA has already been altered prior to their conception. So the genetic risk then interacts with neighborhood characteristics, stress, social support. In early life, this can be altered by education, quality education, parent and caregiver well-being, childhood adversity. In midlife, occupation, health literacy, social status, and years of education are the predominantly affecting factors. And as you can see, the risk just accumulates with lifetime. All right, so while there has been significant focus on studying the biological determinants of health, there is very little systemic, there's very little systematic evidence on the social determinants of mental health and dementia. So I was fortunate enough to participate in a scoping review with Dr. Tempe and Dr. Jeste, as well as people from other institutions to do a scoping review on the social determinants of mental health as they relate to dementia. Our initial search was broad and resulted in 1,769 articles, which we then reviewed based on the abstract to narrow down the focus. And the pattern that emerged was a focus on social connectedness, social isolation, and loneliness. So our aim was to conduct a scoping review of how social connectedness is related to Alzheimer's disease and related dementias. Based on our preliminary search, we revised the terms and updated our search. And some very interesting terms came up. Pets, social robots, marriage, right? And so the social robots and technology piece is particularly interesting, and I'm excited to hear Erlin Lin's presentation just in a little bit about how technology can mitigate social isolation and loneliness. So these are our methods for our study. We used PubMed and based CINAHL and PsychInfo to identify meta-analyses and systematic reviews that looked at Alzheimer's disease or dementia and looked at these terms of social isolation and loneliness. And we eventually included 19 reports of studies, and these studies were all meta-analyses and systematic reviews. So we basically found that low levels of social isolation were related to improved late-life cognitive functioning. Conversely, poor social engagement, being unmarried, and poor social network led to an increased relative risk for dementia. And non-cognitive, non-physical leisure activities were correlated with a decreased risk for cognitive decline, whereas it's not really clear how early childhood factors, higher level of education, social network, and social support mitigated the impact of social connectedness on the risk for cognitive decline. So just to drive this home a third time, loneliness was related to an increased risk of Alzheimer's disease. And being in a relationship or married, living with other people, so even people who were unmarried but were living with other people. So for example, in a multi-generational home where there are a lot of relatives, living with a partner that you're not married to, all of this did have a positive impact on cognitive decline. Weekly interactions with family and friends, weekly group engagements, and crucially, never feeling lonely. So we talked about social isolation and the feeling of loneliness, and the feeling of loneliness itself, regardless of how many people are around you, has an impact on cognitive decline. And never feeling lonely is related to slower cognitive decline. Participation in social group activities or associations, so again, mitigating the feeling of loneliness, increasing social connections, was related to a decreased risk of dementia. And this is from one of the studies. What do we know about social and non-social factors influencing the pathway from cognitive health to dementia? It's a systematic review of reviews, which was included in our review. And the positive relationships, the protective factors of cognitive decline or dementia include participation in social activities, larger social network, living with others, greater social support, frequent social contact, social engagement, feeling satisfied with social ties, and being married, all had a positive impact on cognitive function. Whereas the risk factors of cognitive decline or dementia, so loneliness, less social participation, a small social network or a poor social network, so quality and quantity are both important, low social engagement, low satisfaction with social ties, and being lifelong single or widowed or divorced all had a negative impact on social function. So I'm going to wrap this up and I'm just as excited as you are to hear from Dr. Jeste about more about social determinants of mental health. So in conclusion, the multiple studies suggest that there is an association between decreased risk of adverse cognitive outcomes in older adults with increased lifetime social connectedness throughout. So I hope that you're making some social connections at APA and going to some of the social events. It's for your cognitive health. Thank you. Good afternoon, and thank you, Dr. Tampi, for inviting me here. I've had the pleasure and honor of working with Dr. Tampi as well as Dr. Joshi and Mr. Len's department, especially his boss, John Torres. So I'm going to talk on social determinants of mental health. You already heard a lot from Dr. Joshi, so I will add a few things to that so I don't have any relevant conflicts. So I'm going to begin with social determinants of mental health, the history of the development of this concept. Next I will talk about social determinants of health in schizophrenia, and finally where we go from here, the next steps. So historical background. The idea that social factors affect health is not new at all. It has been known for centuries. Ancient Greeks, 6th century BCE, they considered physical and social determinants of health and emphasized supportive environments and healthy public policies. But the first time the word social determinant of health was used and promoted in the health care field was by the World Health Organization, WHO. They published the first book on this subject in 1998, and that was followed by books in 2002, 2008, and a number of times since then. Believe it or not, there is now a bipartisan congressional caucus on social determinants of health. So we all can be sure that the Congress is going to solve all our problems of social determinants, like racism, poverty, hunger, homelessness. We can be sure now, so we don't have to worry about that anymore. On the other side, social determinants of health really are an important factor that have not received enough attention in medicine, especially psychiatry. So the WHO defined these as the conditions in the environments in which people are born, live, learn, work, play, worship, and age, which have a major impact on a wide range of health functioning and quality of life outcomes, risk, and health inequity. Examples of the social determinants, as Dr. Joshi mentioned, include social inclusion or exclusion, early life adversities, discrimination, socioeconomic status, housing instability, and access to care. And looking at them is important for providing direction to develop strategies for prevention of illnesses. We mostly focus on treatment of illnesses, but if you want to prevent, really we need to start at the social determinant level. Two years ago, Dr. Vivian Pender became the president of the American Psychiatric Association, and she made social determinants of mental health her presidential theme. She appointed a task force on the subject, and she appointed me as the chair of the task force. It had four workgroups, clinical workgroup, research and education workgroup, public health workgroup, and policy workgroup. And the workgroup, all of these workgroups, the task force, worked together for a year, and I'll talk about some of the products that came out of that. But the question was this, that the WHO published on social determinants of health in general, right, that apply to all of medicine. Do we really need to think about social determinants of mental health? That is, determinants that are relevant to people with mental illnesses. The answer is yes. Why? Several reasons. The first is that 75% of serious mental illnesses, including schizophrenia, bipolar, depression, PTSD, substance use, they begin in early life, childhood, teenagers, or early 20s, which means that people with mental illnesses are going to, if they're affected by the social determinant, that effect is going to last an entire lifespan, unlike, say, people with cancer who develop cancer at the age of 60, right? Then they will be facing that only for 20 years. Secondly, and this is really one of the most embarrassing facts for U.S., U.S. is the only country, known country, in which there are more people with serious mental illnesses who are in prisons than in hospitals. Really, I mean, it speaks so... We should be ashamed of that. It really speaks so poorly about the criminal justice system in which we equate delusions and hallucinations with criminality. Another serious problem with serious mental illness is that there is a big mortality gap. People with schizophrenia die 15 to 20 years younger than the general population. So there is accelerated aging. A 45-year-old person with schizophrenia is like a 70-year-old normal, so-called normal subject. Not only that, but we published a review sometime just in the last four or five years that the mortality gap between serious mental illnesses and general population has increased in the last several decades. Why has it increased? Not because more people with schizophrenia are dying. It is because the general population is living longer. And that we know, right? Longevity is increasing. Why is it increasing? Partly because there is better nutrition, better environment. There is more, for example, we talk about reducing smoking and so on and so forth. Unfortunately, those benefits, social benefits, don't get transmitted to people with serious mental illnesses. So what are the social determinants of mental health that are unique to mental health? Stigma against mental illnesses. I mean, there is a far bigger problem than for many other medical illnesses. Healthcare inequities for psychiatric patients. Again, there is such healthcare disparity between people with and without mental illnesses. Criminal justice system. Neighborhood adversities. Homelessness. Social media. Social media, by the way, I mean, this is something that has become an increasing problem, especially for younger people. On the other hand, as Dr. Joshi mentioned, there are positive factors like community-level resilience that help some communities when there is a major disaster. PTSD is a common phenomenon. Not in all communities. Some communities experience post-traumatic growth. So that's a positive factor. So our task force actually did a lot of things. We published papers in JAMA Psychiatry, American Journal of Geriatric Psychiatry, multiple presentations at national conferences, white papers submitted to Board of Trustees, a new caucus has been formed now at the APA on Social Determinants of Mental Health led by Eric Rafla Yan, and a new staff position was created for Associate Director for Social Determinants of Mental Health. So that's about Social Determinants of Mental Health in general. What about schizophrenia? So before talking about schizophrenia, just think about this, that the Social Determinants of Health were described by WHO 25 years ago, right? And so we are, and there is even a Congressional Caucus that has become a priority for NIH and CDC and so on. How has that changed our clinical practice? Answer is zero. Especially in psychiatry, there are some areas such as oncology and cardiology that are done much more in terms of this, not psychiatry. Which is strange, actually, because this is social, and psychiatry, we should know what is social, right? So part of the problem is that there is no definition of social determinant. The list that originally WHO had included 15, now there are 150 social determinants. There is no consensus list of factors that are social determinant. So what are social and what are not social determinant? Actually, Professor Vincenzo De Nicolais here is President of the World Association of Social Psychiatry, and he and I and some of the colleagues, we have been talking about how to do this in a meaningful way, defining social in the Social Determinant of Health. And one of the problems is there are very few valid and pragmatic clinical measures. In clinical practice, we hardly ever ask a person about the neighborhood, housing instability, transportation problem, food insecurity, right? And part of the problem is there are no well-designed longitudinal studies to show causality. We call this social determinant. Do we really know they are determinant? Most of the studies are cross-sectional, in which all that we show is association, not causality by a long shot. And lastly, there are also lack of hypothesis-driven biological studies with appropriate biomarkers. Social determinants act on biology. There is no question about that. That is why they impact health, increase illnesses, and cause death. So that's why we put together a group to look at social determinants of health in schizophrenia spectrum psychotic disorders. We wanted to look at what is the literature. And so we did meta-analysis of nine meta-analyses of social determinants of mental health in schizophrenia. And we looked at the clinical outcomes, incidence of schizophrenia, prevalence, symptoms, hospitalization. And we found that the specific social determinants of mental health that we looked at, and I will talk about them in the next few slides, had medium to large effect sizes. Of course, there are limitations of these studies. Most of them are cross-sectional. They cannot prove causality. Heterogeneous measures were not always valid, often not. Neglect of confounding factors, and exclusion of positive factors. There are very few, almost no study of social resilience in schizophrenia, for example. So let me just give you examples of the impacts or associations of social determinants with clinical outcomes. One of the most important social determinants for schizophrenia is early life adversity. So these are the adversities during the prenatal, postnatal period, and early childhood. Look at this. Early life adversities are associated with increased risk of later developing schizophrenia, another non-affective psychosis. The odds ratio is 2.81. That means if you have early life adversities, you are 2.8 times more likely to have schizophrenia. Wow. The genes account for no more than probably 10, 15, 20% of the illness. And here we are talking about almost three times increased incidence. Wow, right? Social network. Social network size inversely associated with overall psychopathology. The G values, it's the regression analysis correlation, 0.53, which is moderate to high. But racial discrimination, racism has become a big problem. Perceived racial or ethnic discrimination associated with psychotic symptoms, odds ratio 1.82, psychotic experience is 1.94. So blacks are almost twice as likely to be diagnosed with schizophrenia than whites. And there is no biology for that, because the incidence of schizophrenia is the same all over the world, in Africa, Europe, Australia, Asia. And still, so part of the difference is because of the way the marginalized communities are treated and they receive resources. Another social determinant, urban versus rural setting. Urban setting are much more likely to be associated with schizophrenia, odds ratio of 1.64. Living in lower socioeconomic status areas, neighborhoods, poor neighborhoods, the psychosis incidence rate ratio is 1.78. And we are talking about big numbers, right? Immigrants versus non-immigrants. Relative risk of psychosis, 1.81. Social fragmentation. Four times higher rate of schizophrenia prevalence in areas with highest versus lowest level of social fragmentation. Homelessness. The poor prevalence of schizophrenia in homeless people. So that means if you look at the homeless population overall, you find that more than 10% have schizophrenia. What is the prevalence in the general population? The prevalence in the general population is 0.3%. 1% is the lifetime incidence. Prevalence is 0.3%. So here we are talking about 10%, right? So almost 30 times as high as in the general population. Incarceration. Prevalence of any psychosis, 3.6% to 3.9%. Food insecurity. If you look at people with schizophrenia, 45% of them have significant food insecurity. So again, you see a lot of evidence about the impact of association of the social determinants with schizophrenia risk. The biology. Again, I don't want to go into details. I'll be happy to answer any questions. But very briefly, most of the social determinants, they impact psychological processes like... Look at the second column. Social epigenetics. So these factors affect the genes that are associated with social behavior. Allostatic load. That means excessive stress. Accelerated inflammation. As I said, there's accelerated aging and schizophrenia, and especially associated with greater inflammation. Microbiome. And these changes affect brain. They affect the structure of the brain, function of the brain, chemistry, and neuroplasticity. And that then leads to psychotic symptoms, cognitive impairments, impact on quality of well-being, and ultimately comorbidity and mortality. So where do we go from here? What can we do? One thing we need to do is we need to look at the positive social determinants of health. Again, I think we found not one paper, let alone meta-analysis, on factors like social resilience or other positive factors, social compassion on schizophrenia. They are important factors, clearly. I said, yeah, no studies of family or community level. An assessment of positive factors is rare, even at individual level. How many clinicians assess things like resilience? Does the EHR require us to assess resilience? The answer is no. We assess depression, anxiety, right? Suicidality. That's great. We have to. We don't ask about resilience, optimism, social support, what they like about themselves. The EHR evaluations, yes. I think that's a big problem in our health care system today, that if you look at the data, the data don't help you because the data just don't exist. And because they don't exist, we don't expect people to ask questions. The only thing we ask patients is, what is wrong with you? What are the risk factors? We don't ask them, what is right with you? What do you like about yourself? It is really critical to assess and promote positive social determinants of mental health. Because even when you talk about these social determinants, like migration, racism, poverty, there are people who have migrated, who are minoritized communities, or poor people who do very well, right? So they have the same adverse social determinant, but they do well. Why? Because probably they have more personal resilience and other personal positive factors that help them overcome those things. So what should we do? I think we really need, and this is the burden is on the researchers, I think. We need to develop measures for these psychosocial factors that are valid, but pragmatic. We cannot have a 100-item questionnaire, right? But we cannot have a single question either. So some of us are beginning to look at developing a questionnaire that could be administered to every single patient. And the questionnaire does not have to be given by the physician, not at all. Physicians don't have time, you know. But it can be done online, and it can be done by patients or their families at home before they come in, and they do it every three months. And then the psychiatry cycle, whosoever sees the patient has the questions in their hand. It is just like you order routine blood work, and then the physician looks at the blood work, and then you can decide, you know, whether hemoglobin A1C is high or whatever. Likewise, that information should be available to the clinician so it can affect what you do in the treatment. So there are scales, actually validated scales, such as experience of discrimination, childhood trauma questionnaire, UCLA loneliness scale, social network schedule, San Diego Wisdom Scale, Connor Davidson Resilience Scale. So there are majors, and we are hoping to come up with something that can be used widely. Interventions. Interventions. I think there is an exciting area. I think that because so little has been done, we can have some exciting potential individual level intervention. For example, psychotherapy. I mean, psychotherapy is not new, of course. But recent research shows that psychotherapy affects gene expression. It produces changes in social epigenetics. So I talked about early life adversity producing epigenetic changes in some genes. Psychotherapy in later life can reverse those changes. Again, there are some new data that are coming that are purely exciting. Inflammation, as I said, is a big problem, but again, right now we don't have any good anti-inflammatory agent, but we will. Microbiome and probiotics. Again, right now we don't have any, but we will. Depression is an example of a hormone that is associated with increased compassion. That is what the mother feels for the baby. And brain stimulation. Again, this is the beginning. Now there is repetitive brain stimulation, deep brain stimulation, and so in near future we will be able to stimulate specific areas and suppress other areas. One thing in which U.S. has not done well, but U.K. and Europe have done much better, is what is called social prescribing. This is one of the core pillars of the U.K. model of personalized patient care. What is social prescribing? Social prescribing means that when we see a patient, as a physician, clinician, we refer the patient to certain social agencies or departments, something outside, outside healthcare. So there are these social prescribing link workers, they focus on what matters to me, to co-produce a simple personalized care and support plan to connect people to activities, groups, and services in their community to meet the practical, social, and emotional needs that affect their health and well-being. Give you an example. Some patients miss appointments because they don't have transportation. We never ask them about do they have difficulty with transportation. Do they have difficulty with walking because there is really only highway nearby. We don't ask those questions. So if we ask a question and we find there is a problem, then we can refer them to some social agency that can help take care of that problem. Again, very simple problem, very simple solution, which will have clear impact on the health. So that is social prescribing. So this is somewhat similar to the role that in the U.S., the case workers and paraprofessionals used to have, but again, that thing has disappeared almost today. So I'm coming to the end of my talk. So this is at the individual level. What about the public health policies, practices, and laws? Some things have to be done at the community level. I mean, clearly, we need to, racism, for example, I mean, we really need to act on it at the community level, and this is something the government and the policy makers should do. Same thing about homelessness, right? Advocacy at local, state, and central government levels. Media outreach, especially social media. Media play a major role, and social media really has become, when the social media first came into being, it was exciting. You know, you could connect with anybody, anytime, all over the world. What has happened, especially for younger people, they have caused far more problems. Number of suicides are attributable to social media. Number of suicides has gone up in younger people, as young as 10 years old, which have led to increased suicides, so adolescents, teenagers, as well as people in their 20s. And international collaborations are critical, because some other countries are doing things that we can imitate here. So summary of next steps. What should we do? So first is, we need to have clinical assessments of these social determinants. We've got to assess them. If we don't assess them, what can we do about them? Secondly, we need to have biomarkers. Again, these social determinants act through biology. There's no such thing as social versus biological. It's all psychobiosocial, right? So looking at the biomarkers will be helpful. Third step is, we need to set up interventions that focus on specific social determinants. Prevention. Again, if we do something to the social determinants, we can prevent illnesses. For example, if we were to remove early life adversities, let's say, some or other could prevent, that will reduce the prevalence, incidence and prevalence of so many psychotic illnesses significantly more than any medical treatment can ever do. And clearly, we need socioeconomic policies for promoting equity, diversity and inclusion. So thank you for your attention, and I'm sure there will be time for question and answer later. So thank you. All right. Thank you very much, everybody. To provide a bit of an overview for what I'm going to be covering following up on Dr. Este and Dr. PJ's work, both of them provided a brilliant overview of social determinants of health, particularly in schizophrenia and in dementia. My goal for my presentation is going to be to focus in a little bit more narrowly and talk about some exploratory research and potential future directions for digital measurements of social connection behavior, particularly implementation of digital measurements for individuals suffering from schizophrenia. So in contrast to positive symptoms and negative symptoms, which rightly have a really prominent area of focus both for research and intervention, social functioning has received proportionately less attention, though it's increasingly acknowledged as a significant area of focus, as was already somewhat covered by the previous presentations. Social functioning and social connectedness have a really significant impact on individual mental health and health care outcomes and are a significant driver of disability and individual suffering from schizophrenia. Now, to provide a little bit of context for what's meant by social functioning, social functioning, speaking very broadly, can encompass the individual's ability to fulfill socially outlined roles, that can be worker, house caretaker, or friend, and encompassed within that definition is the wide array of difficulties that individuals with schizophrenia can suffer from, challenges to interpersonal relationships, challenges to maintaining housing, jobs, and social connection. However, despite its clinical significance and increased attention, there are a large number of methodological challenges with measuring social functioning and social behavior. This has been recorded back in a number of literature reviews dating all the way back to 2007, and many measurements of social functioning behavior suffer from issues of validity, reliability, and really specifically for the purpose of this presentation, responsiveness and testing against ecologically valid measurements. Part of these issues are due to the implementation of these measurements. Many of them are extremely long, not readily administered, and as a result can really easily lean into issues of recall bias. If in a study a participant is reporting something back over the course of even a month, there can be a significant shift between the reality of one's experience of social connectedness, their own social network, and what they might report at the time. And while these challenges are not new, and I don't mean to present this as dismissing standard measurements of social functioning in their entirety, there's a need for novel methods, particularly those that are sensitive to change over time. And so with this, and with the challenges of measurement, I want to present digital tools, specifically smartphone technology, as a scalable way of monitoring day-to-day shifts in social functioning that can really capture the dynamicism of this and help to measure this clinically significant outcome. So like symptomology, social functioning and social behavior can fluctuate very significantly over time on a day-to-day basis, on a month-to-month basis. Individuals might change their social patterns and social capabilities based on their symptoms, based on changes to their housing location, based on shifts in job opportunities. And notably, these changes do not necessarily move linearly with symptoms, though there's a notable relationship between social functioning and negative symptoms. It's not necessarily a given that they're going to change together, and there have been instances in which patients might experience remission of positive symptoms, but impairment in social functioning may last for much longer. In addition to this, it's also notable that pen and paper measurements of social functioning do not necessarily encapture the degree to which social behavior has moved online. Many individuals might gain social connection through social media, they might engage in social activities online through calls, et cetera, something which likely increased significantly over the course of the pandemic as well. And these things have a capability of being captured by digital tools, but not necessarily by standard measurements. And this brings us to the concept of digital phenotyping. Very broadly speaking, digital phenotyping is the use of mobile devices to identify markers of disorders through the collection of behavioral data. And that data is usually broken down into what we might refer to as active and passive data, and this is where we're going to really get into some of the logistics of the data collection. So active data is data that very generally just means that it requires active engagement from the user to be collected. So what this might look like is you might have a smartphone app, example image shown on the left there, with ecological momentary assessment surveys built into it. To be clear, not all EMA constitutes active data, but EMA collected through a smartphone would. Those surveys could be administered multiple times per day, multiple times per week, over an extended course of time, but require active input from the user, but can be done as the user patient goes about the world and can be gathered over the course of time as seen in these examples with mood and anxiety. One can collect a substantial volume of data points from survey input over an extended period of time and begin to see trends and shifts in social functioning and social connectedness. Now, passive data is a little bit more nebulous and a little bit more broad, but passive data generally refers to data that, in the opposition of active data, requires no active engagement from the user to be collected. This generally leverages tools already built into the smartphone to derive really broad measurements of people's trends and behavior. So the key example of this is GPS data. A lot of people's social behavior, although as I stated before, not necessarily for social behavior that takes place on social media, but a lot of social behavior is related to mobility, movement, and location. GPS can be leveraged to extract trends such as how much time someone spends at home, how much someone travels, and how stable are the locations that someone visits. It's a little bit difficult to see with the coloration on the slide here, but what can then be done from extracting those trends is one can actually cross-reference the passive data and active data. So this graph on the right here illustrates data points that are gathered over the course of a little over a month from active data, those are the lines there, for anxiety, sense of dysfunction, and depression levels, and in contrast, they can be compared to the amount of time someone's spending at home. Now mind you, the meaning of these data will vary from individual to individual, different people have different home situations, and for someone, one person spending a lot of time at home might be a very positive experience, and for others, it might be a very negative one, so these all have to be taken within a context, but they can provide a really substantial volume of data that can give us a really fine-grained perception of how people move throughout their day. And then from that, this is more or less an elaboration on what I illustrated before, this is sort of an overview of what a pipeline of this data might look like, so you have passive data being extracted into trends for location, sleep, physical activity, meshed with daily journaling, EMA surveys, all of which can be used to gain a clearer picture into things like social exposure, self-care activities, and cross-referenced with someone's sense of social connectedness. And this can be used on an individual basis, a lot of mental health apps are leveraged in a self-help capacity, but a potentially rich area of development is the implementation of these tools in real-time monitoring interventions, which can help clinicians to engage with patients really dynamically in their shifts, which is particularly pertinent for disorders such as schizophrenia, where people are at risk for relapse. Prior research has illustrated that digital monitoring using smartphones is both feasible and acceptable for individuals suffering with schizophrenia for periods of over a year, but despite this potential, there's been relatively little focus on actually evaluating how all of these things can be pipelined together. So with that, some of the work that we did that I want to highlight more or less as a prompt for future exploration, built off of this previous study, which leveraged a number of digital metrics, very high-volume active data collection on social functioning, alongside use of a standard social functioning measure, that's the social functioning scale. Now the social functioning scale is certainly not the only social functioning measure, nor necessarily the gold standard, but it is one of the ones that is most frequently used, particularly in comparison to EMA and passive data collection. The social functioning scale is also pertinent because it has several significant subdomains of social functioning. Social functioning, as said, there's many different capacities in which someone can function socially, and given that, not all of those dimensions will change in the same capacity. So in the case of this study, it reported correlations between passively and active collected data measuring social functioning and prosocial activities, interpersonal behavior, and employment and occupation. Now as a follow-up to that, one of the main questions that's born out of this exploration is, to what degree can digital data serve as a proxy for standard measurements? Can these be effectively leveraged in the wild, and will they be able to measure social functioning at least roughly as well as standard measurements can, but with a much higher level of granularity? And to follow up on that, using regressive models to predict social functioning scale values, we found that using passive and active data on social behavior from over a year collected from patients with suffering from schizophrenia had an overall similar performance to those using the past month's social functioning score. So this was done both leveraging the total social functioning scale score as well as the scores for social functioning sub-dimensions. So how well can passive and active data used to examine people's social behavior predict someone's social functioning score, comparison between the digital data and the paper data. And what we found is that roughly it was able to do so. In particular, it was most effective at predicting social engagement. That's not just how frequently is someone socializing, but how present are they in the social interactions. Are they anxious? Do they feel included in employment, which is relatively self-explanatory. Those particular sub-domains were the highest performing in their predictive capacity. Now I want to be very clear, all of this research is very tentative, and part of the reason that I presented on this particular topic is because it's quite understudied, but I think is a potentially fruitful area for further exploration, particularly given the significance of social functioning as a determinant for mental health. So with that, some of the future directions are further exploration of the validity and reliability of ecological measurements, that's digital phenotyping, to make sure that those same results displayed earlier are replicable across samples, and particularly across cultural social contexts, to help encapsulate those determinants earlier mentioned. In addition to that, looking at how shifts in these specific domains of social functioning might vary over time. As I said before, social functioning and its particular facets are dynamic, but different facets of social functioning may not be equally dynamic for different people. And finally, as is commonly stated, there's a great benefit to be gained from studies that can conduct this sort of exploration over very large samples and over a long period of time, utilizing longitudinal data. There are a relatively larger number of studies looking specifically at the use of active data over short periods of time, one week, two weeks, and those studies have tremendous value and are particularly applicable due to their straightforward feasibility, but there's a lot of knowledge to be gleaned from the use of longitudinal research, and this is particularly going to be necessary if we're going to explore the possibility of leveraging these sorts of technologies and interventions. That's everything from me. Thank you all very much. You know, the session is being recorded. Thank you. Hi. Dr. Jaising, I have a couple of questions. So the first question I have is, you know, in, we have institutions that prepare us to go to school, go to college, go to work, we don't have a social structure that prepares us for life after retirement. What do you think about what could be done as the population ages and, you know, people lose social connections, a purpose, a meaning, you know, opportunities to interact with others. So that is my first question. Second question is, in Indian philosophy, as you age, there is a dictate to withdraw from social attachments, withdraw from worldly activities, you know, and go in a direction of more self-reflection, isolation. That goes almost converse with what we are recommending here. What are your thoughts about that? Thank you for great questions. The first one regarding retirement, that is really a common problem. So there are studies of purpose in life, meaning in life, strong data suggesting that purpose in life is associated with better health, even greater longevity. So typically when we start at the age of, say, 20s, one is lacking a purpose. You are struggling to find out what do you want to be, what do you want to, you know, what education, job, et cetera. Slowly we gain that, and you do functioning, and then you have family, and then you feel good that you have purpose in life. And then after so many years of work, once you leave for, especially for men, the job is their life. And when the job ends, the life for them ends, and the purpose, importantly. So what is the purpose in living beyond that? Because they're no longer useful for their co-workers. So it is important, you know, that we often talk about retirement planning in terms of finances. We've got to talk about retirement planning in terms of purpose. What will you do after retirement? And there are some great examples of people who have done various things of different kinds, even among physicians, actually. Wrote some paper about that. So there are some people who continue doing whatever they have been doing. For example, the cardiac surgeon who died at the age of 95. In his later life, he continued seeing patients. I mean, of course, he didn't do surgery, but so he continued his clinical practice, right? That's one good thing about being an MD, is that you can continue working, right, forever. There's another one in Japan. He died at the age of 108, longest living. What he did after his 80th birthday was he became much more socially active. And he started helping other people. He would work 18 hours a day, essentially for community service purposes. He also started writing books. He wrote something like 50 books after his age, 80. So he kept himself active by helping others. There are other people who then switched to something that they used to do in children. Say somebody was very fond of music, but they couldn't really practice music. Then they would go back, and then they would do very well. So again, it's a question of finding a purpose that is meaningful to you. Plan for that years before you retire. So that's how you can do that. Regarding the second question about the Indian society sort of recommending withdrawal from the society, it is not just Indian, actually. Even in the West, until about 100 years ago or so, it was recommended that as people get older, they start withdrawing, because as it is, they're going to die. Their relatives are going to die. So why not actively do that instead of letting it happen? That's not actually a good idea at all. Because as you heard from all of the speakers, social connections are the single most important social determinant. And we need to find ways in which we can keep the social connection going. It can be social media, if they are used positively for older people. But there are other ways. And I really think intergenerational activities, by the way, are great. So again, for when older people work with younger. So those are the kinds of things that need to be practiced. Hi, Lawrence Wu. I'm an older psychiatrist also. Trained in the UK, but now working back in my home country of Australia, in Perth, Western Australia. I say that because in the last 10 or 15 years, one big movement in UK and in Australia is the concept of recovery. And I haven't really heard that phrase used in any of the presentations. And when I say recovery in mental health, it's not recovery from the mental health conditions, because as we know, they remain chronic and lifetime. But it's really the concept of recovery of one's life with the mental illness. Because as we know, many of our patients have extremely socially impoverished lives where they don't do much except spend all day smoking and drinking coffee and tea. Which we see that in our wards historically have been incredibly impoverished, especially in the government system. And improving a great deal now because of this, with a lot more activities and things like that. Things that we have seen in countries like Australia, I've kind of commented about the US. But these activities were much more prevalent in the private sector, with more money obviously, than in the government sector. But having said that, certainly me working primarily within the government sector, a big thing that we have been doing in all the teams that we do is about social engagement. And also that leverage is also on the comment that you said, you know, Josh just said about older people having, after your retirement, what gets you out of bed each day? And something I always say to my older adults is, you know, we all need that in life which makes us get out of bed each day. Anyway, but my question really was, you know, is that concept of recovery, is that kind of well known? Is that a trend in American practice? Thank you for your question and your comment. I think it's certainly a very important concept. And I think while we don't use the term recovery in the same manner, we, in part of, I mean, treatment from a mental illness is not just pharmacological treatment. A comprehensive treatment from a mental illness should be biopsychosocial. And increasing that social fodder, increasing that sense of purpose, is just as part of the treatment in a psychiatric or cognitive illness as the medication is. I think particularly in neurocognitive disorders, this is even more salient. So the majority of my work is with people with various types of major neurocognitive disorders. And medications don't work that well. You know, and there are times that, you know, in the initial referral, I have a patient who's been diagnosed and they're already on Denapazil from a community PCP or a neurologist. So is my work done for, not really, actually, right? So even though the diagnosis has been made and the medication has been started, I'm not gonna change the medication for the rest of their lives. I still spend substantial amounts of time in psychoeducation, increasing supports, immobilizing social resources, and increasing that sense of purpose. And trying to bring a sense of purpose that somebody with cognitive disorder can continue to do. And so, you know, a lot of times I'll ask patients because, I mean, they can no longer work, right? They can no longer drive. There's crippling loss of independence. There's deteriorating functionality. There's a need to start delegating IADLs to other people who can do it more competently, right? So there's a severe, this is a severe narcissistic injury. So I'll ask them, what do you like to do and what can you do? No matter how cognitively impaired somebody is, even in stages of severe cognitive impairment, there is something you can do, right? So if you used to like to do quilting, maybe you can't do complex new patterns anymore, but you can cut cloth into squares. Right? So if you like children, if you like animals, maybe you can't independently drive and go somewhere, but you can partner with a volunteer service to help package boxes. So no matter how cognitively impaired or psychiatrically, you know, deteriorated somebody is, there is something they can do to increase that sense of purpose and that sense of quality of life. I'm just gonna answer that. You know, I also wanted to say that, I think there is a dichotomy in mental illness versus physical illness. You recover from physical illness, you recover from pneumonia, you recover from urinary tract infection, but do you ever really recover from schizophrenia, bipolar disorder, dementia? And I think that still persists, but now we know that each of these mental illnesses, phenotypically, they may look very similar, but genotypically, they're actually very different illnesses in that. So I think we are, I think with the DHS, I think with the DSM-IV-TR and DSM-V, you're starting to see that you're sitting, schizophrenia, multiple episodes, currently in remission. So at least we're accepting that people can have no symptoms and exist well. And I think we are, as we know more neurobiology and as we know more social, psychiatry part of it, I think people will realize that mental illness can also, there can be recovery. I think we're still, it's a legacy of thoughts from previously. Thank you. Thank you for a wonderful presentation on this often neglected and inspiring others and people like me to think about this dialogue. And my question is pertaining to that dialogue. I'm a part of a nonprofit organization that addresses the mental health needs of the South Asians in the US. And what we do is we do outreach programs, which consists of lectures, workshops. We do mental health screenings at temples, mosques, gurudwaras, and things like that. So my question is, what can you suggest to us, to me, that I can bring and use that platform to bring awareness of this and to raise the importance of the social determinants and improve the quality of life of people at the grassroots level? Again, first of all, compliments for the work you have been doing through your nonprofit. I think that that's a really wonderful example. And in a way, you're already doing something related to social determinant because religiosity actually is a social determinant. People who are religious and they belong to a religious group and they follow certain practices, say going to a temple or a mosque or synagogue, church, regularly, you have a network of people that think like you, that believe, their beliefs are similar to yours. And then you have activities that are healthy activities, right? And there's also hope, belief, and so on. So that's actually a very positive social connection that exists. And so you are already doing that, in a way. So that's helpful. I mean, of course, extreme, you know, extreme, every religion has extremists and that's really not useful. But religiosity or spirituality, sometimes people might be religious, but if they believe in some higher spirit or whatever, something that you don't see, that becomes actually a source of social support. Because even if they don't have anybody else, you know, that sometimes happens for people who are solitary confinement, for example. Then they think about if they believe in God or spirit or something like that. They're always in contact with that entity. And so they have a connection, they feel good about that. So I think the more we can promote that in people who can use it properly, the better it is. Hello there, I'm Ken Campos, and was also at UCSD with Dr. Jesty long ago. But I have a question particularly for Erland regarding the use of the digital technology and the mobile devices. Over the years in my inpatient hospital work, I noticed a few patients had modern delusions as opposed to, you know, demon possession and whatnot, that someone had implanted a monitoring device, you know, behind their eyes or in their foot or something like that. And then to ask someone with schizophrenia, which might have a potentiality or propensity to these kind of unusual technological modern delusions, were there some dropouts in getting people with schizophrenia diagnosis to use a mobile phone? Yeah, thank you for the question. I would say that there's two facets to the answer, one of which is a straightforward yes. And sort of the framing for the research and interventions that might leverage digital technologies has to be with the utmost transparency. And of course, you know, making space for people who, you know, do not feel comfortable using the technology, the space to leave. The other side of that that I would say is that there have been a reasonable volume of studies using reasonably sized samples. One of the studies that I cited in the presentation has sampled 75 people, all of whom comfortably use the technology for a year. And in addition to that, research into the self-reported desire for people suffering from mental illness, particularly schizophrenia, to use technology has found that the majority of, at least surveyed participants in this particular study that I'm thinking of, I believe it was Ragh et al, were interested in using technology to aid with their mental health. So the answer I would give is that yes, there's a degree to which there are gonna be people who are uncomfortable using the technology and space needs to be made for them to not use the technology. And alternative interventions can be applied there. But there's a substantial enough interest in an openness using technology to facilitate treatment, either on their own or in conjunction with a physician that I think there's still space for that. Thank you for the question. Hi, Vincenzo Di Nicola, World Association for Social Psychiatry. I wear three hats. I'm a social scientist trained as a psychologist. I'm a psychiatrist and I'm a philosopher. I think this was a terrible presentation. And I wanna thank you very much. Here's why. I think it's terrible because what you've done, and I know Dil very well, or I'm getting to know him well, and I really appreciate what you've done, but I think behind the very positive and useful overview is what it does is it embarrassingly shows what a bad job my gang has done translating the social determinants of health into reality. So my critique is not just, I know Sir Michael Marmot, he spoke at our Congress in London recently, and I really value his work. It's probably the most important epidemiological study ever done in the history of humanity. I mean, it by far overshadows the International Pilot Study of Schizophrenia. So the problem is that public health, epidemiology, social determinants of health, they're cruising at 35,000 feet. And it's exciting because it's like being an astronaut or a pilot and seeing the world. It is exciting. But where we fail, and I don't put it on the epidemiologist or Michael Marmot or the public health people, I put it on us, the clinicians, or the people that are supposed to integrate things, we haven't brought it down to ground level. And I think this is where Dr. Jessie's presentation touched me so much. So it's terrible because they're really exposing the fissures and the gaps, and I think so far that are really not justifiable. It's because these communities don't talk to each other. I know I did a doctorate in epidemiology, and I left that community because it was boring. It's not boring, it's exciting, but they didn't talk across to other communities. They have very little interest, actually, in talking to clinicians. Clinicians don't always have the training to understand them or the motivation. And so it's up to people like us to do the translation. So the task I've set for myself, and this is why I'm so grateful to you, this whole panel, and what you represent, is I wanna translate from 35,000 feet to ground level. What does it mean in the clinic? So Henny Nazarella challenged me to do an article for Current Psychiatry, which is for clinicians, to translate into daily practice what the social determinants of health, what social psychiatry could be. And I don't put it on anybody else but us. The social psychiatry, epidemiologists, it's up to us. And what we've seen today is what could happen. So we're really at ground zero. Everything else is just a prologue, and now we can really do the work. So that's why I thank you. But at the same time, a part of me feels really badly that it's taken till 2023 to get that kind of clarity on where we are. Thanks. Thank you, Dr. DiPaola, for that critique, and it's really well-received, and I will make a comment, you know, because we truly are, you know, we truly produce an environment where we live in, and that's how we influence the environment. And I think, unfortunately, the way healthcare has been and is going is, and we talk about this often with Dr. Joste and Dr. Joshi, where in American psychiatry, at least, and if you know, it's mainly driven by each episode of meeting the patient. So it translates into, you see the patient, you bill for a service, and it's done there. So there is no thought about how it's gonna affect. There are very few people who think in a socially positive or socially responsible way, academicians do, I mean, many of us here are that, but 90% of people who will come for this conference here are asking the thing, what can I prescribe to take care of this patient for this episode, not for the whole life history of the illness. And I think that is why American psychiatry and American medicine has not embraced, you know, social determinants of health. People are talking about it now because it's fancy and it's nice, and you can do a lot of things. And as Dr. Joste pointed out, all ills are gonna be sorted now because we have the bipartisan group that makes it. So I think there is complacency thinking that, so because we're talking, there's gonna be a solution. And unfortunately, the reality is, I think it's gonna be more fragmented. Yeah. I worry along with Dr. Joste that it's become a buzzword. And the problem with buzzwords, there's a concept of plastic words. It feels like it means a lot, resilience, development, society, but it's plastic, so it feels good. And you can make it mean whatever you want it to mean, you know, just like, you know, the character in Alice in Wonderland said. But what I really wanna say is, and it's a bit provocative, is, you know, I live in Canada, it's a different social context, and in French Canada, so it's a very different context. But I have to say this, but it took Black Lives Matter for the APA to wake up and look at its own structure, its own issues, and it went from Black Lives Matter and that challenge, you know, Saul Levin has talked to me about that, and then they created, along with the courage of Vivian Pender and Dilip Jeshi, they created the Social Determinants of Health Task Force. But it took a crisis, and a serious social crisis, for people to even take it seriously. Now, that's what I mean, it's terrible and it's good. It's terrible in the sense that, too bad that it took that, but it's good that we finally woke up and are doing it. And I think that's where I really want to thank this group and everything, all the work that's behind it that you do. Took a lot of courage, and I really appreciate that. Thank you. Yes, please. Now we're running out of time, sorry. Really interesting presentation, especially there's been a lot of mention around social determinants and occupation. I'm a social worker myself, and to be honest, a little bit surprised about the lack of mention around, you know, our sort of multidisciplinary colleagues, social workers, OTs, where, you know, social determinants and occupation, it's bread and butter. And I sort of wonder whether you guys think that there might be more of a role of a multidisciplinary approach to sort of better addressing the social determinants of mental health and mental illness. I'm assuming that, you know, psychiatrists and residents, they probably don't, as much as they'd like to, they probably don't have the time to, you know, sort of be addressing all of these things. Everyone's time poor, and, you know, could there be more of a role around sort of having our social worker OT colleagues to, you know, to better achieve these goals? Thank you for that comment. You know, again, same issue that we have is, in at least US psychiatry, and I'm sure the panel will agree, is that we do individual care. I mean, the multidisciplinary teams usually come together, either if you're in a community mental health or if you're in an inpatient unit. But if you're in a individual clinic, it's the physician, whether it's an advanced practice provider, an MD, or anyone else, it's an usual clinician who does that. And even, you know, being the chair of a department, I know that we talk about social determinants, we talk a lot about this, but talking to individual person to do this group is a very difficult task. But people are like, well, time is money. You know, I'm paid by the number of patients I see. How am I gonna do this or spend time? And Alan Anderson was pointing out in our multidisciplinary talk that when he met with internal medicine or family medicine doctors, they asked him, this is great, you're gonna educate us on dementia, that's great, but are you going to pay for the time we spend listening to your talk learning from you? So he said it killed it right there. So people do like the multidisciplinary approach, but then someone has to pay for it, and I think that's the evil that we are running into, where everything is seen as an exchange, you know, of. So thank you for that comment, but I think every discipline is important in the healthcare of an individual. We are all responsible for ours, and the society is responsible for our health. So greatly appreciate that comment. And thank you all for being here, and we want to finish on time. Thank you.

social determinants

mental health

dementia

schizophrenia

isolation

loneliness

cognitive health

social connections

stigma

digital psychiatry

smartphone technology

multidisciplinary approach

healthcare policies