I'm Ron Kennedy Bailey, currently chairman of the Department of Psychiatry here at LSU School of Medicine New Orleans, and also in the role of Assistant Dean for Community Engagement. Very happy to join the group today with this program sponsored educational program by APA. We're addressing issues of the social determinants of mental health. We have two experts in the field today, past presidents, Dr. Vivian Pender and Dr. Elizabeth Jesting, here to begin with comments based on their background of ideas regarding how these particular concerns lead to hurdles and impairment in our ability to provide best quality of care for our patients, both locally, nationally, and I'd argue even internationally. We hope to discuss, I think, over the course of the next hour, some strategies that we think we can use to move forward practically and pragmatically and develop, I think, some theme points, I think, for our members to use and address these concerns for their patients going forward. We'll begin today, again, with Dr. Pender. Dr. Pender, welcome. Thank you. Dr. Bailey. I'm sorry. Dr. Bailey, before we go on, Dr. Pender, I really want to give you your accolades before you have a chance to speak. So let me take this opportunity to say thank you, Dr. Pender, for your vision and for your platform during your presidency with the American Psychiatric Association that was focused on social determinants of health. And I do also want to take this opportunity to thank Dr. Dilip Jesti, who will be speaking after you as the workgroup chair. We are here today, as Dr. Bailey pointed out, as a regrouping, and we're going to map a way forward with timelines and benchmarks to really begin to put the pedal to the metal, for having things that are done that we can actually say that are tangible outcomes of the hard work that has been laid out by you, Dr. Pender, and the work that you've done in the workgroup. And so, again, Dr. Bailey, Dr. Pender, and Dr. Jesti, thank you so much. These are just initial steps to lay the foundation to map things out. And I will now turn the mic over to you, but just wanted to make sure that you got your roses. Thank you. Thank you so much. I really appreciate that. I'm going to share my screen. Can you see that? Yes. Yes. Okay. So, again, thank you very much for organizing these panels, and to all those who have worked so diligently on this topic. Developing a vision for my presidential theme was consistent with my observations of the status of psychiatric health care over decades, my decades of experience, teaching primarily first and second year medical students, psychiatric residents, and psychoanalytic candidates, combined with my public health experience consulting for other countries' health care systems, evaluating asylum seekers, treating homelessness in New York City, and victims of human trafficking, it confirmed that most psychiatric patients suffer from lifelong adverse experiences, either secondary to a serious mental illness, or secondary to a traumatic experience. Together with colleagues who also felt frustrated that we were essentially doing tertiary care, I began to think about prevention and how social determinants of mental health could be applied. The COVID pandemic, especially, had exposed fatal disparities in access to health care for large segments of the population, and clearly a public health perspective would have helped. Social determinants are the most modifiable targets to improve mental health. Although the field of psychiatry has progressed over the years, even today, psychiatry has few biomarkers and few cures for the disorders we treat. As a book reviewer for The Lancet, I had the opportunity to read these two books. Andrew Skull is a prominent social historian who has written extensively about the social history of medicine and psychiatry. His book, Desperate Remedies, brings us face-to-face with a hard truth. Psychiatry has been stalled for hundreds of years at the symptom phase of medical understanding, largely lacking ideological knowledge of pathophysiology, pathology, and the molecular basis for disease. Skull, after losing his son to drug addiction, wrote a desperate plea for psychiatry to find cures. And Tom Insell's 2022 book is a capstone to his long career as head of the National Institute of Mental Health. Ironically, Insell, a noted psychopharmacologist, emphasizes in the book social solutions for those suffering from mental illness. In my opinion, the medical model may only apply to those individuals with a serious mental illness and serves to stigmatize those who don't fit the norm but are being asked to adapt to their environment with sometimes catastrophic repercussions. A public health prevention model would address this critical problem. I'd like to begin with a bit of information about the history of social determinants of mental health. Beginning in the early 19th century, the Industrial Revolution led to increased disease and poverty, which prompted an exploration of the social roots of disease. The German physician Rudolf Virchow, the founder of cellular pathology, wrote that medicine needed to enter the political and social realm to fulfill its purpose. He was a vigorous advocate for social reform and is thought of as one of the founders of social psychiatry. In 1949, the NIMH was created, and that was thought to be around the same time as the beginning of a more organized social psychiatry. In the 1950s, deinstitutionalization began, especially with the availability of Thorazine, and there was a rise in community psychiatry as a specialty, followed sometime later with public psychiatry fellowships. And then in the 1980s, the second Whitehall study out of the UK showed a steep inverse association between social class as assessed by grade of employment and mortality from a wide range of diseases. Just a note about the World Health Organization, at its beginning in 1948, it defined total health as a state of complete physical, mental, and social well-being, including mental health. They had a seven-year action plan from 2013 to 2020, and their findings, again, confirmed that social determinants played a large part in good mental health and well-being. Returning to the APA, I found that since its inception, I just want to note this, that the APA has always had an interest in community and socially-based programs. The APA Foundation, in particular, their stellar programs are especially focused on community and cultural differences, and their aim to promote mental health literacy, connect underserved minoritized communities to needed care, and to shift attitudes. They have now trained over 2,000 fellows. In 2015, the psychiatric online journal, Focus, published an article by Michael Compton and Ruth Shim on social determinants of mental health, followed by their groundbreaking book that they edited in 2016, which is now required reading for all. And then around that time, the Division of Equity and Inclusion became the Division of Diversity and Health Equity. In 2018, the APA published a position statement that mostly focused on disparities. And then in 2021, in the beginning of my presidency, a task force was established, chaired by Dr. Dilip Jesti, and 12 valuable members who are participating today. The task force did tremendous work and produced webinars, white papers, educational and research resources, journal articles, and recommendations. And I believe all of that can be found on the APA website. As an outcome of the task force, an Office of Social Determinants was established in 2022 under DDHE, and that was a direct output of the task force. So I guess I won't go through this in detail. We all know the basic definition of social determinants are the structural conditions that people are exposed to across their life cycle. And in particular, the negative impacts include poverty, childhood adversity, violence, unemployment, low socioeconomic status, low education, food insecurity, poor housing in neighborhoods, discrimination including racism, sexism, and stigma, and limited access to healthcare, exposure to the criminal justice system, and the results of climate change and migration. Some researchers have narrowed it down to the top three of poverty, violence, and migration that have the largest combined impact. More patients may become, in fact, more vulnerable in the current environment. In 2021, the Lancet wrote an editorial, this was at the beginning of my presidency, about the APA and its presidential theme. The editorial was called Brain Health and Its Social Determinants. They noted that the pendulum has swung between biological and sociological for over 50 years. They quoted me saying we need to be more aware of the broader context in which an illness occurred and how that context has shaped the health outcome. They also noted the conclusion of the Lancet Commission on Global Mental Health, supporting the consistent strong association between social disadvantage and poor mental health. They commented that U.S. psychiatrists seem to be heavily influenced by the biomedical pharmaceutical model, although current treatments are somewhat limited. Also commenting on this is a World Psychiatry publication in 2023 that the current state of psychiatric treatments reflects limited knowledge of pathophysiology, lack of biomarkers, insufficient treatment of psychiatric disorders, and current research challenges. So the time has come, and this is an excellent time for the APA to revisit the social determinants and the status of psychiatry and the way it is being practiced. Until we have a more scientific understanding of how the brain functions, we can use a prevention approach for not only individual patients, but actually large populations. So primary prevention is like a vaccine. If there's something we can do to prevent a disorder from occurring in the first place, that disorder could be eradicated. For example, trauma, such as violence, can be prevented, and that would mitigate all of the disorders following that traumatic event. Another example is childhood adversity. If there is a policy that can be put in place to prevent it, that would prevent the disorders that occur as a result of the chronic stress of either being the object of adversity or witnessing it. The Lancet editorial cited the Biden administration's child tax policies that lifted millions of children out of poverty, that reduced child adversity. Unfortunately, it only lasted a year. Secondary prevention is intervening at an early age of an illness. For example, the well-known benefits of early intervention for first episode psychosis. But another might be the early diagnosis of autism or ADD, so that there isn't a secondary layer of personality and self-esteem disruption. Psychiatric treatments can be considered a secondary intervention, but they usually occur after years of either a mental illness that wasn't acknowledged or was treated inadequately. That prevention approach could be taught to medical students from their first year of medical school. Then they're learning, interviewing, no matter which specialty they eventually choose. I did some of this with the medical students over the years that I taught them. We can also think about how we could recommend that all residency training be changed to include social determinants and mental health. Even departments of surgery were interested in this. And finally, propose a public health psychiatry fellowship that is different from a public psychiatry fellowship. It would be based on public health principles and modeling, especially prevention, using a psychiatric approach to healthcare systems. So these are just some examples of what we did with medical students and residents. For example, instead of asking a patient for a chief complaint, the implication meaning what's wrong with you, they could approach the patient just as you would in public health and ask, what do you need? How can I help you? They will tell you. We found that when we use this approach, they know what they need. For example, protection from abusers, a safe place to live and buy groceries or health insurance. They may say, I need you to take care of my symptom or pain, or I need you to do something about my stress, and that's fair enough. But sometimes they'll say, if you ask, I need an apartment or a better place to live. I need more money. Another preventable social factor is how much violence are they living with? If we don't ask about domestic violence, we may never find out that it is, in fact, the cause of all of their psychiatric symptoms. This approach to the patient is more empathic, and I believe that it would facilitate collaboration with the patient. In terms of diagnosis, we would need to include social determinants in a differential diagnosis, and there are ICD-10 Z codes for treatment reimbursement that can be used to discuss with a patient to note a socially determined factor. And last but not least is advocacy. There has been a United States House of Representatives Caucus on Social Determinants of Health, which we hope will continue. It is bipartisan, and we have worked with them. A few years ago during my presidency, they sent us a long questionnaire to help them with their goals. We pointed to studies that show that basic income programs that provide families with small amounts of money reduce family stress, reduce incidents of violence, fewer calls to the police, fewer school dropout rates, lower rates of use of alcohol and drugs, lower rates of home eviction, fewer accidents, and fewer suicides. Minimal income provisions also improved stable employment, general health, and a sense of well-being. Given the current political environment, this theme is more important than ever, and I look forward to the rest of the speakers, and I will now turn it over to Dr. Dilip Jesti, who chaired the task force. Thank you. Thank you very much. Let me upload my slides. Hello. At peace. Is there something? Do I need to be co-host to share the slides? Jesse, you have co-host privileges already. So as long as you have your slides up, just hit the share at the bottom of the screen. Okay, so thank you very much again for having me here. It's a great meeting. So let me start with the Lancet editorial that Dr. Pender mentioned. This is really a rare time for a medical journal, not psychiatry, medical journal like Lancet to write an editorial complementing APA precedent for developing a new theme of social determinants of mental health and developing a task force on that. So it really was a pioneering thing for us to do that, and I'm just delighted to be on that task force. What I'm going to do is now talk about things that have happened since then, things that have happened since 2022. One thing is that several of us got together and we have established global research network on social determinants of mental health, and this is the website, socialdeterminantsofhealthnetwork.org, and the goal is to improve clinical health care of people with mental illnesses based on quality research evidence. And leadership includes a number of people, including Michael Compton, Subodh Tabe, who is the dean of the Royal College of Psychiatrists, Dolores Malaspina, Eric Raflajan, Ellen Sachs, Shekhar Saxena, who headed the WHO mental health division until a few years ago, and Alta Stewart. And our goal is to, of course, strongly collaborate with APA, but also with the Royal College of Psychiatrists and World Health Organization and we started monthly webinars, which have been going on for about a year and a half now, well. We have been talking with the APA about starting an educational course on social determinants, also talking with the Royal College of Psychiatrists, and very recently starting podcasts on this thing, which will be useful for public at large. Of course, public advocacy is a major goal, and last but not least, supporting young clinicians and researchers. So this network is open to all, and everybody is welcome to join. It doesn't cost anything. So we all know about the WHO report. The Joint Commission reported in 2022, and the Joint Commission is really an important entity. They manage about 20,000 healthcare systems in the US, and they have been around since 1951. In a recent report, they talked about health-related social needs. They said these are actually the proximate cause of poor health outcome for individual patients, in contrast to what the WHO described as the social determinants of health, which is better suited for describing population. So according to the Joint Commission, social determinants of health are related to population, whereas health-related social needs apply to individual patients. And they said that understanding individual patients' social needs, health-related, is critical for practical patient-centered care plans. And as an example, they said, for example, if someone with cancer needs radiation, that person would not be able to get that treatment if they don't have transportation to go to the treatment place. So that kind of a social determinant has impact on the outcomes of cancer. And of course, it applies even more so to people with mental illnesses. And the Joint Commission has ensured that many health organizations today have begun to implement routine screening for health-related social needs and referring patients to community resources as a part of their treatment plan. So here we are talking about medicine in general, not psychiatry. But these assessments actually are very useful. So these are not research assessments. They are actually clinical assessments that can be done in every single patient. So some examples of what the Joint Commission has developed. One, the measure of housing stability. The question is, what is your housing stability today? And the answer may be, I have housing, or I have housing today, but I'm worried about losing housing in near future, or I do not have housing. I'm staying with others in a hotel. Food security. In the past 12 months, you worried that you may run out of money before you have any money to buy more food. Never true, sometimes true, often true. Transportation needs. In the past 12 months, the lack of transportation affected you from different types of important regular activity. No, yes, it has kept me from non-medical meeting, appointments, work, or getting things I need. And most important, yes, it has kept me from medical appointments or getting medication. So something like transportation really can affect the healthcare in a major way. Another is on utility needs. In the last 12 months, have the electric, gas, and other utility companies have threatened to shut off services in your home? No, yes, already shut off. And last but not least, interpersonal safety. How often does anyone, including your family members, physically hurt you, or insert or talk down to you, threaten you with harm, scream or curse at you? And all of these things, you say never, rarely, sometimes, rarely, often, frequently. These are pretty simple questions that can be completed by patients or their families at home, or social worker, case manager can give those. And increasingly, they are being used in certain healthcare systems. For example, like New York State actually requires that, and various universities are also beginning to use that. So one of our goals was really looking at the evidence, because I think what we need in this area, just like any other area, is really solid evidence, or some at least supportive evidence for that. And we have been doing a number of reviews of social determinants in different mental conditions, and looking at what the literature shows. So we started with a literature review of schizophrenia social determinants. So this is a paper on overview of 13 meta-analysis of social determinants related to schizophrenia. Michael Compton was one of the co-authors of this paper. We found that the highest odds ratio of the social determinants that were looked at were childhood abuse and neglect. It increased the odds of having schizophrenia 2.814, so almost three-fourths. Then comes food insecurity, odds ratio of 2.71. So again, almost three times higher risk of schizophrenia, we have food insecurity. Then comes something also very important, especially in the U.S., perceived or experienced racial discrimination, essentially racism. The studies in the U.S. show that the odds of having schizophrenia in a Black are 1.94 times those of having schizophrenia in a White. Almost twice the risk of schizophrenia in Blacks than in White. And this is not at all biological, because the prevalence and incidence of schizophrenia are same in Africa as they are in Europe, North America, and other parts of the world. So why is it so much higher here? Because of racism, racial discrimination. And of course, this applies not only to Blacks, but also to other marginalized communities, but there are more studies in this topic. Immigrants. Similarly, the migrants, the odds ratio is 1.8, so almost two. So migrants also have a higher risk of having schizophrenia. Then we looked at some studies which had compared the prevalence of schizophrenia in different kinds of population. They found that a socially fragmented neighborhood, that is where, you know, the different groups move out, move in, smaller families, greater divorce rate, all of those things. Four times higher prevalence of schizophrenia in areas with the highest social fragmentation compared to those with lowest social fragmentation. Incarceration. Schizophrenia prevalence is 3.6 to 3.9 percent. The overall prevalence of schizophrenia in the general population is 0.3 percent. So think about this, this is 10 times higher, 3.6 to 3.9 percent in people who are incarcerated. And finally, homelessness. It is even higher, 10 percent, more than 10 percent in different studies. So there is no question really that these social determinants are associated with increased risk of schizophrenia. Next, we published an umbrella review of 26 meta-analyses that looked at major depressive disorder, social determinants and major depressive disorder. And the ones I will show you are the ones that had medium to large effect sizes using Cohen's tree. So you can see here, the childhood psychological abuse, childhood sexual abuse in females, childhood physical abuse, childhood neglect, all of those significantly increase the risk of major depression. So does a death of a family member, as well as food insecurity. And these things may happen early in life, but they have impact on the rest of the life. Just like schizophrenia, again, some populations are at a higher risk of major depression. Immigration. Among immigrants, the prevalence is 17 to 31 percent. The prevalence of major depressive disorder in the overall population, by the way, is 7 percent. It varies, but roughly 7 percent. So you can see that here it is two to four times as high in immigrants. Incarceration, 12 to 21 percent. Homelessness, 13 to 26 percent. So these populations, again, migrants, incarcerated people, homeless people, they have a higher risk of schizophrenia, as well as major depressive disorder. By the way, Dr. Shekhar Saxena, who headed the WHO mental health division for 10 years, previously now at Harvard, he was one of the co-authors. And very recently, just last week, actually, we had this paper accepted by JAMA psychiatry. This is on social determinants of mental health associated with suicidal behavior. This is an umbrella review of 46 meta-analysis and systematic review on suicidality. So we looked at the social determinants associated with three different things, suicidal mortality, suicidal attempts, and suicidal ideation. Okay. Suicidal mortality, the strongest social determinants were incarceration, exposure to other suicide or parent suicide, firearm access, divorce, and joblessness. And when I say strongest, I mean D, if excised, would be greater than 0.5, sometimes greater than 0.8. Suicide attempts, the social determinants were history of childhood maltreatment. And that doesn't affect suicidality only as kids, but it affects even later in life. Sexual assault, gender and sexual minority status, given the strong discrimination of and bias against LGBTQ individuals. You can see the importance of that in terms of suicidal attempts. Homelessness and incarceration, especially in females, leading to suicidal attempts. And finally, suicidal ideation. Once again, identification as bisexual person, homelessness, and intimate partner violence in women. So the point here is that there is really strong evidence showing the relationship of some social determinant to these major mental illnesses and other things. But you know, social determinants are not only adverse social determinants, there are some positive social determinants, protective social determinants. And in our treatment, we can use them also. So not just control the adverse ones, but also enhance the positive ones. In schizophrenia, the best positive social determinant is large social network. People with schizophrenia with large social networks are more likely to have sustained remission or recovery. Major depressive disorder, parental care. I talked about parental death being a risk factor. Parental care is a positive factor for reducing the risk of major depressive disorder, not just in childhood, but even in later life. Dementia. Access to education and social support are two really important social determinants. And one thing actually I should mention, most people don't know that the incidence of dementia is actually going down in the last few decades. It is going down in older people. And the main reason, nobody knows exactly, but the usual thinking is that the main reason is that older people now have access to better education than they had 30, 40 years ago. Suicide mortality, religious affiliation, and being married are two of the most significant positive factors to reduce the risk of suicidal mortality. But suicidal attempt and suicidal ideation in youth, school connectedness. I mean, some ways you can see the social connections are the most important social determinant, and you can see them in terms of social network, social support, and school connectedness. Just a couple of things, and then I will end. As Dr. Pender mentioned, social determinants, we have to look at biology also. It is not social versus biological. We published a review, Dolores Malaspina and Keira Baggott were important co-authors. So if you think about social determinants, like early life adversity, social disconnection, poverty, food insecurity, studies have shown that they are associated with pathophysiological processes that affect the whole body. Social epigenetics. Actually, Dolores has done some amazing work on social epigenetics related to social determinants, especially including racism. Allostatic load. You know, most of the social determinants produce toxic stress, and that leads to allostatic load, which is very measurable with epinephrine, norepinephrine, and a bunch of other things. There's accelerated inflammation and accelerated aging. And even microbiome, the gut microbiome, actually has impact on social determinant and vice versa. So studies have shown that these social determinants do have biological effect, and then these general body biological effects affect the brain. And again, studies have shown that they affect structure of the brain, function of the brain, chemistry of the brain, and neuroplasticity. These things then result in mental health outcome, as well as physical health outcomes. Psychopathology, positive negative symptoms of schizophrenia, depression, and so on. Cognitive impairment. Comorbidities of different kinds, which also tend to lead to shorter lifespan. And most people with serious mental illnesses live 10 to 15 years shorter. So one thing is that, so we can see how these biological factors can make the physical and mental health worse, but then worse health actually worsens the social determinants. So the relationship between social determinants and health outcome is not one-sided. It is bi-directional. Social determinants worsen the health, but worse health worsens the social determinant, and it becomes a vicious circle. And this is my last slide. So what do we do in terms of treatment? Again, the US system is not good at all. The UK has somewhat better system in terms of social prescribing, where all patients are seen by social workers, link workers. And actually in the US, studies are starting using case manager, for example. And a case manager, usually a social worker, is a key practitioner or navigator who evaluates plans, implements coordinates, and prioritizes services based on individual's needs, and then can offer self-management support in close collaboration with healthcare, social, and community partners. And I'm sure the rest of the meeting today, we'll talk about the various interventions at individual level, as well as at community level. But let me stop here. And again, thank you for your attention. I appreciate that. Well, thank you both so very much for such timely, I think, and pertinent information and reality, as these are issues that I think many externally are aware can be problematic in their lives. We're probably not acutely understanding exactly how they work, I think, cumulatively to affect our ability to treat patients and manage those concerns. So, really outstanding comments from both Drs. Pender and Jesse, thank you very much. So, we'll jump right into it. I'm very excited to, I think, have four or five key questions that I'd like to pose. And really, the first one, I think, speaks to a point that, Dr. Jesse, you just kind of commented on about assessments, and the question reads, you know, how are social determinants of health assessments influenced your approach to diagnosing and developing treatment plans for patients? I think your last slide spoke about the key value, I think, of the multidisciplinary treatment team, and the remarkable importance of having a case manager handle the addressment issues, I think, over time. I'd love to hear your thoughts, both of you, on that discussion, how these issues affect our ability to conduct optimal assessments. Vivian, do you want to start first, and then? No, please. Okay. So, I think assessment of social determinants is really important. Unfortunately, the EHR, in most settings, doesn't include social determinants. And I think that is a major mistake. And what we need are not, you know, research-focused social assessment, not at all. But this practical assessment, as I showed you in the slides by the Joint Commission, these are the things we need to ask our patients. And we, in a sense, are not psychiatrists, but the social worker, case manager. And this can be done online. Because that helps us know which social determinants are important for a given patient. The same social determinants are not important for all patients, so some have some. So doing this kind of general assessment helps us know. And then that information should go to the treating clinician. And that example, actually, that Joint Commission gave, I love that example, that patient with the cancer who needs radiation, what would affect the treatment is having transportation to go to the facility. If they don't have transportation, they won't go, they'll miss that. So it is not the medical risk factor, it's just the availability of daily transportation that has a severe impact on the prognosis. And I think in psychiatry, that's even more so, because our patients typically, you know, lower socioeconomic status, non-availability of transportation that is affordable, non-availability of food, homelessness, these are common issues in our patients. So we've got to assess them in some way, and that should be part of the EHR, I think. Dr. Pinto, I'd love to hear your comments regarding issues, regarding assessments. Sure. Yeah, I totally agree with Dr. Jesty, that this has to be part of the general assessments of all patients. And that was why I particularly thought of this kind of top-down approach, you know, speak to all the medical departments in the hospital, all the medical students, so that we could catch, especially the students at an early age, when they're just learning how to assess a patient, that they must ask about some of these social determinants to include in their diagnosis and their treatment plan. And it should, I mean, our idea was, and we spoke to at least my medical school, Weill Cornell Medical College, about the necessity for all physicians to have this kind of, include social determinants in all of their assessments, even if it's a broken bone, you know, they have to include these things. We know that, this was a while ago, but 60% of prescriptions never get filled. And that is across the board, not only psychotropic medications, but even antibiotics. So, you know, that has to do with social determinants as well, and has to be included in assessments. But to respond, I clearly think that the idea or concept that these issues are kind of multi-determinant based on a variety of factors means a lot, I think, for our patients who often struggle to manage a variety of moving balls in their own lives, job and work and money and family, and issues of health are the often pick a back burner, which is one reason why we often have trouble getting any response, let alone getting a full remission. So thank you both very much for those comments. Next, Dr. Pinto, I'd like to kind of begin with you this time. I think that the follow-up is, what specific factors of social determinants of health do you find most relevant in impacting these mental health outcomes? I'll return to the slides, I think, that showed the variety of variables that increase the risk of schizophrenia, the one about African-Americans in this country versus in a continent of Africa is a certain one that I've been aware of throughout my entire life. I've always been surprised that you see very different responses to persons of African descent in the Caribbean, as well as in Africa, compared to African persons of background who are here in the U.S. Issues, I think, of discriminatory bias, described as racism earlier, I think, clearly, one issue that raises its head, but I think now with individuals based on the immigration challenges we have in our country, one can only imagine that those same kind of problems are likely to entail in other racial groups. Dr. Pinto, any thoughts about that, issues regarding what are the most relevant factors, I think, in your assessments? Ms. Hedding? Yes. I think I mentioned that the three factors, three key factors that some of the researchers felt were most important was poverty, violence, and migration or immigration, being displaced. Those accounted for most of the distress that people or lack of well-being or symptoms that people felt. The COVID pandemic is clear proof. I think the statistics were that, at least in the New York City area, that people of color, either Black or Hispanic, were up to four times more likely to die from COVID than white people were. It was clear, clear and present. So with those kinds of statistics, I think we need to just keep talking about them, and hopefully it'll become a priority to people. Well, as a follow-up, before I go to Jesse, I'd like to actually ask you to comment on the increase of consideration now that we may struggle with more income inequality. You're in New York City, certainly a place of remarkable variability between those who have a whole lot and those who may have a lot less. These are challenges that I think we're seeing really in many parts of the country, and we're interested in whether there are any strategies that may be working or even considered for psychiatrists to be mindful of, of how we might think about that with patients where the huge divide between the haves and have-nots is making it harder for us to do our jobs in addressing people with mental health challenges. Yeah, I mean, that's a very good point. I agree. In a sense, zip code is one of the strongest predictors of mortality in the U.S. It's really, I mean, as Vivian talked about the COVID, and you can see where the mortality is highest, and it was often in communities with high numbers of marginalized, discriminated people. So there is clearly something wrong with the system, and, but what needs to happen? So I think, so we need interventions at different level, obviously. One is, of course, at the policy level, at the highest level. One would be, on the other hand, at the individual level, in the sense, some kind of psychotherapy that helps people sort of reduce the stress associated with that, but then also important is the social aspect of therapy, in the sense, improving their social connections. For example, the ethnic minority community, if there's a strong, the large number of people who are living from that community that live together, that actually is a positive social determinant. For example, in San Diego, there are a number of Hispanics, because we are next to Mexico, but if there are communities in which a number of people of Hispanic origin, if they live, their relationship is much better among themselves, and their, actually, well-being is also better. So if you're discriminated against, actually having your own community, and I think that, but also one thing I want to stress is the most important social determinant in general is social connection. This is based on hundreds, if not thousands, of studies, and these are studies across the world including hundreds of thousands of people, some with illnesses, some without illnesses. Social connection is the most important, I mean, it is, the human race, actually, depends on social connection for our survival, let alone thriving, and this is something as psychiatrists we need to focus on also. That is, not only the individual patient's treatment, but also what we can do to improve their social connection, and not just a number of social connections, the quality of the social connection. You know, sometimes these days, with social media, there are lots of social connections, they are not helpful. So I think that should be also a part of, in which psychiatrists will work with social workers and other social practitioners, whatever we call them, and because, again, to improve the social connection, the quality of social connection, I think will be very important. Do you have a follow-up, Dr. Pinder? Yes, I agree that we need to speak to each patient and see what their social circumstances are. I think that, you know, given the current environment, and there have always been non-profit organizations, many, many non-profit organizations that support positive social determinants, you know, a lot of our patients don't know about those agencies, that community agencies that are readily available. So unless we ask, or the patients are asked by someone, then they never find out, and they can never be directed to them. But I think we may see, some people are predicting now, that there's going to be more and more non-profit organizations that will provide protections for people, especially people with vulnerabilities, like our patients, or in other circumstances. They will provide resources and protections for more communities. A great point. And I want to move to the chat, while we wait until the end, then we get some very good information here. It actually comes from one of the Task Force members, Ken Thompson, speaking about the need for us to think more broadly about these issues of the social determinants, I think, of mental health, because, as both of you have pointed out, they really come from such a variety of variables, as people's backgrounds come into play, maybe different types of treatment strategies are likely to be more effective. And he kind of speaks about suggesting that maybe we need to be much more mindful of the dynamic ever-changing aspects, I think, of mental health life of many of our patients, especially as we begin to think about these differing populations. And I would even add the differing variables that I think influence them. I'm from Texas. I like to make the comment a lot. I miss saying that you're from Texas as much as you can, but the reality is, Texas is, I think, as diverse and broad internationally, I would argue, as California and New York, that I'm not so sure many Americans are mindful of. Even my own hometown, Boma, Texas, remarkably varied now. And it may even be 1 third, 1 third, or 30, 30, 30, 10% Asian, as far as the makeup, ethnic makeup. Very, very different than it was when I finished high school there 40 years ago. That type dynamic change, I think, is occurring in many parts, I think, of our country, many other states as well. That's an issue I think for us to be very, very mindful of. Again, I'd come to the two of you to make any comments regarding, for us to think more broadly about how people come to these issues very differently. Any thoughts? I 100% agree with you about the dynamic nature of the social determinants. I think at the societal level, the next four years, God knows what's going to happen. I'm sure we are all worried about how things may change. But even at the individual patient level, it's really important to assess these social determinants every few months, every three months at least, because these things change. So for example, somebody may be doing well, may not have a problem, but suddenly loses a job. Then that joblessness becomes a new social determinant. And that associated the socioeconomic, emotional, social connection, those will be affected. So the important thing is that we should not assess them only at baseline or only at intake, something like that. We can't assess them every few months because they don't change. And that will affect, again, what kind of therapy we give or what kind of therapy we provide. Again, it's like the loss of near and dear ones, somebody's sickness. But children, of course, they're even more important because of what happens to parents and the family. And these days, social media have become a major social determinant of health, which are adversely affecting the teenagers and young adults. And this is changing. Again, the culture is changing also with that. So I think it is important that we don't think about the social determinants as a sort of static thing that we measure once and we, no, we've got to measure them from time to time. Dr. Pinder, any thoughts? Yes, the dynamic nature, I think, goes back to the dynamic nature of the brain and actually how pliable it is and how human beings can use one part of the brain to compensate for another part of the brain. And I think, so I think we have to remember that kind of fundamental functioning of the brain that it is dynamic and there can be some, I don't know, new processes formed and to keep that optimistic view in mind. And that really, I think, speaks to the next point I want to ask is this issue about how we collect data and whether we do it in an accurate and effective way. We describe addressing more challenges in getting accurate data. The reality is there are a lot of reasons for the data, I think, on our patients being accurate, inability to access them, inability for them to share it in a much more progressive and promulgated fashion. Also, just some of the historical biases about conducting projects or studies, I think, in patients with brain illness. Many variables, I think, have made this very difficult, I think, for us as a profession. Interesting thoughts that either two of you may have regarding our importance of collecting data that's accurate and effective and for us to be able to extrapolate that over time to create some strategies that are better for our treatment of our patients. Dr. Jassi? Yeah, I think this is really an important point. Collecting data is critical. I think because ultimately if we want the policies to change, they will ask for, what is the evidence for that? And so for that, collecting data is essential for us to change the system. Because there we can show that, look, if you do these things, your health improves and the healthcare costs come down. Once we see that, then the politicians will do something about that. But also, I think it is for individual patients' treatment. They become very helpful, how the changes are occurring that they work. Vivian, you want to say something and then I'll come back. But collecting data, right. Yeah, I think that even in the current environment, the government and other corporations look to the APA and psychiatrists as experts. We are considered experts in the field and they will, I believe, continue to consult us. And given the stress of the current environment, we may be consulted even more often and we will have a lot to contribute in that regard. Yeah, one point I want to add there, again, from the APA perspective, I really think the DSM-VI should include social determinants as a separate axis and they should be collected for every patient when he or she is seen and those data documented. I really think, again, it doesn't mean that one has to look at 100 social determinants, no, but you can select five, six that are more important one. But unless they become a part of something like DSM or ICD, I worry that otherwise they won't be collected and they need to be collected. By definition. A couple of the really good points that have kind of come in give credit to our doctors, Eric Raffaoon, I think who led the caucus, asked him, what do you think about the ability and the process of our members who are in smaller, even solo practices being able to kind of collect this type data and implement these strategies to address better understanding of social determinants for mental health, I think, in our patients. I would ask a second one at the same time, also I think Dr. Abbasi points out that many of our members have actually adverse impacted themselves as the doctors or the clinicians by many of these challenges. And I might that actually affect their ability to practice good quality psychiatry going forward. And also I think the ability to manage patients with similar challenges. So what about small practices and solo practices and another about the impact on our members themselves in this entire sphere of influence? Well, I could start with that. What I have done with individual patients is to have a kind of checklist and check in with yourselves. And I have spoken to colleagues about that as well, actually family members as well. It's a stressful time. And I think everybody is being impacted in the current environment. The most important thing, or one of the most important things that a person can do is check in with yourself and acknowledge how are you feeling? And then have another list of things that you can do about it. And Dr. Jeste mentioned social connectedness. That is hugely important so that people don't feel isolated or inundated with whatever is on the news. And I know some of us have stopped watching the news, turn off the television, even the newspapers. And that's not a bad recommendation too. That's one of the protective measures a person can take is to insulate themselves from the stressful environment. So how do we incorporate this into a private or solo practice? I think it's very easy. You can very readily, it's like a review of systems, included in your review of systems, just like you go from head to toe, do you have any of this and this and this? You can do the same thing with the social determinants, your finances, your home. You can easily ask people about that. And a follow-up to that question, actually on that point, I think Dr. Pinder, is how might the APA help members? I think particularly in smaller practices to be able to integrate some of these things kind of going forward. I think I mentioned at the beginning, we have pretty good educational programs that I think are beneficial in that regard. This would be another element of value added, I think, to membership, if our members across the country were able to find ways to ensure they were practicing, addressing these particular concerns with their patients too. Any thoughts? Yes. No, I agree. The APA could definitely, and the members look to the APA, as well as many other, as I mentioned, non-APA members, agencies and government, they look to the APA for this kind of guidance. So yes, it could be distributed and available to people. I like it. Dr. Jess, any comments? Yeah, no, I agree with what you said 100%. One other thing I want to, related thing I want to add is both at individual level and public level, one thing that is happening for the last 25 years is loneliness pandemic. Now, this is something the WHO talked about, our Surgeon General, Vivek Murthy, has talked about that. There is no question that there is a loneliness pandemic. People often don't realize average lifespan in the US fell before COVID. It fell in 2015, 16, 17 because of loneliness-related condition. Suicides went up, opioid abuse-related deaths have increased tenfold in the last 15 years. That is, again, there are multiple reasons, obviously, but the main reason is loneliness. Loneliness is something that both in individual practice as well as elsewhere, I think got to be looked at and asked the patient. And so there are even a four-item scale that can be done, UCLA loneliness scale. But if a person is feeling lonely, that doesn't mean they're necessarily socially isolated. That means they don't feel that they have good connection, just like Dr. Pender mentioned right now. So people don't want to watch TV, don't want to read newspapers, and that's good. But then they still have social media and that worsens it. So I think one thing probably that should happen for every patient, whether in the case or not, is for the psychiatrists to check out loneliness and then see how they... Loneliness doesn't mean being alone. Loneliness means feeling distressed by being alone. And so I think everyone should talk about the patient, but do you feel distressed when you're alone and what can be done to reduce that? This idea about feeling distressed in the problematic aspect, I think many of us are kind of increasingly mindful of, but probably need to be much more aware of and how we use that to address patients. So I think both of you are outstanding points. I think we are on time. I want to thank Dr. Guy and the group for giving us a 15-minute earlier start. So we actually have 15 more minutes, even though we're right at 60 minutes. So I think we're good. Is that correct, Dr. Guy? Yes, well, thank you all so much. At this time, what we will do is we'll have a little bit of a break to give everyone a break and also use this time as kind of reflection time to really jot down some really, a variety of the important components that were mentioned throughout this presentation and session, because we're going to circle back to that at the end of our time together. So you have about a 10-minute break, 10, 15-minute break, give or take, and then we'll be back at 2 p.m. for our second session on advocacy, collaboration, and community engagement. I want to thank Dr. Jesty and Dr. Pinder. Outstanding comments, really appreciate it. We all learned a lot today. And I just want to thank everyone for, and all of you, Dr. Guy and Dr. Bailey, Dr. Jesty, and all of the participants for continuing on this theme and making it even a larger program than I had envisioned in the first place. So thank you. No, I agree, 100%. So again, I also want to thank Dr. Guy and Dr. Bailey, Dr. Pinder, and the rest of the group. I think this is something really that is important, and I'm delighted the way it's being done. So thank you all.

social determinants

mental health

APA program

Dr. Vivian Pender

Dr. Dilip Jesti

health care access

COVID-19 disparities

psychiatric assessments

policy changes

preventive approach